They range in nature from measuring the prevalence of daily restraint use to reporting the actual percentage of restraint hours. Accredited nursing homes are also using some of the ORYX restraint-related measures for long term care. We have already received some feedback from accredited organizations that the use of ORYX measures has helped them improve their restraint use. The occurrence of a restraint-related death should not be kept either from the public or from those with quality oversight responsibility. Organizations can underscore their own commitment to change by publicizing the interventions taken following a restraint-related death.
Bad things happen, even in health care organizations otherwise providing good health care.
However, a pattern of poor performance or a documented resistance to resolving quality or safety problems that place patients at risk for further serious occurrences should not be kept from the public. The Joint Commission has taken an aggressive approach to public disclosure for some time, and makes performance reports on individual accredited organizations available to the public at no charge. When root cause analysis information is shared with oversight bodies, a powerful source of information on appropriate, and even best practices is continually being created and expanded. The Joint Commission is already credited with saved lives by alerting health care organizations about dangerous practices that have come to light under our sentinel event program, and suggesting ways to prevent future sentinel events. A case in point is our experience in guiding hospitals in the appropriate storage of potassium chloride.