The Joint Commission advises that healthcare facilities create a culture of safety that promotes reporting near misses, precursor events, and serious safety events to promote a learning culture. The Joint Commission requires disclosure to the patient (POA, surrogate, or statutory decision-maker) when an adverse event occurs, as follows:

1) There is an effect on the patient that was not discussed in advance as a known risk.

2) When the event necessitates a change in the patient’s care

3) If the event potentially poses an important risk to the patient’s future health, including minor or immaterial changes,

4) For events involving providing a treatment or procedure without the patient’s consent.