Joint Commission Connect -

/ Report a Safety Event about a Health Care Organization

Thank you for taking the time to share your patient safety concern or event regarding a Joint Commission accredited or certified organization. The Joint Commission takes any information about one of our accredited or certified organizations seriously.

Please complete the following to submit a safety concern or event regarding a Joint Commission accredited or certified organization. (Note: if you cannot locate an organization within the dropdown menu, the organization may not be accredited or certified by The Joint Commission.)

Please read the following The Joint Commission Disclaimer before proceeding.

Disclaimer:
  1.  The Joint Commission does not evaluate the care of an individual, or whether that care was appropriate. Instead, our evaluation focuses on
       processes that are required within our standards.

  2.  Issues related to billing, insurance or labor disputes are not within The Joint Commission Standards. We encourage you to contact the
       organization directly for resolution.

  3.  If confidentiality is not waived, we may still act on your reported safety concerns following our established processes for
       anonymous reporting. Anonymous reporting is no promise of confidentiality since the organization could independently investigate and become
       aware of your identity.

  4.  Please be aware that in line with our Public Information Policy, we cannot provide you with the organization's response should an inquiry be
       pursued.

I have read and understand The Joint Commission Disclaimer.

Health Care Organization Information = Required

1. Select the state/country	2. Select the city	3. Select the health care organization
where the incident occurred:	where the incident occurred:	where the incident occurred:

Type of Organization:
Organization Name:
Country:
Organization Phone Number:
Organization Street Address:
City:
State:
Zip Code:

Please provide your information below so The Joint Commission can contact you if there is a need for additional information regarding your safety concern or event, as well as to provide you with updates regarding the status of your submitted safety concern or event. Providing an email address is required to enable further review of your reported concern.

Source Information = Required

I am:
Do you wish to remain anonymous? *	Yes No
May we contact you if we need more information related to the incident? *	Yes No
Salutation:
First Name:
Middle Initial:
Last Name:
Email (why is this required?):
Suffix:
Professional Credentials:
Street Address:
City:
State:
Zip:
Telephone:		Ext:
Fax:		Ext:
Your Company Name:

Incident Information = Required

Date safety event occurred(mm/dd/yyyy):

What is the nature of the patient safety incident you are reporting? Physical or mental harm that occurred
Unsafe practices or conditions that occurred, which could result in harm

Which of these most accurately describes the harm experienced?

Incident Narrative: Provide a brief overview of your safety event. Please limit your narrative to 3 pages (15,000 characters).

Have the events you are reporting, or similar type events, occurred before? Yes
No

How often do they occur?

Are these events ongoing? Yes
No

Are you aware of any actions that were taken to prevent further events? Yes
No
Not Sure

Have you reported this information elsewhere? Yes
No

Confidentiality Waiver (Please read the following before submitting your safety concern or event) = Required

Thank you for taking the time to share your patient safety concern. The Joint Commission is here to help organizations improve. We will use your report to better understand systems of care and guide improvement.

We will review your report and determine how best to evaluate your concerns. This could include contacting the organization about your concern.

Should we decide to contact the organization about your concern, please confirm whether you give The Joint Commission permission to:

Release your name as the source of this concern and share a copy of the information you have sent to The Joint Commission with the organization.

Please select one:

Yes, I give The Joint Commission permission to share my name, as the source of information and share a copy of the information I have
sent with the organization.

If yes, please provide your first and last name in source information section
No, The Joint Commission may not share my name as source and a copy of the information may not be shared with the organization.

Please be advised:

Permission to share may not result in an inquiry, but it will enable sharing your name as source and a copy of the information should The Joint Commission decide to write the organization about your concern.
If confidentiality is not waived, we may still act on your reported safety concerns following our established processes for anonymous reporting. Anonymous reporting is no promise of confidentiality since the organization could independently investigate and become aware of your identity.

Thank you for bringing your concerns to our attention and helping us with our mission of continuously improving healthcare.