Reporting Medical Errors & Concerns to The Joint Commission & Its Role in Patient Safety
- EvaluCare
- May 25, 2025
- 9 min read
Updated: 6 days ago
When patients or their families experience harm or have serious concerns about the quality of care received, they may feel uncertain about the next steps. The first step should always be to work with your providers and the organizations they are a part of to resolve concerns. In healthcare there are defined resources and pathways to address patient concerns. That is not the only avenue for action. Reporting the issue to The Joint Commission (TJC), the leading accrediting body for healthcare organizations in the United States can also be a useful option. Filing a complaint with TJC not only brings attention to potential safety concerns but also initiates a process that can lead to significant improvements in healthcare practices while elevating the potential failure for tracking and trending nationally.
Understanding The Joint Commission's Role
The Joint Commission is a nonprofit organization that accredits and certifies over 22,000 healthcare organizations and programs in the U.S. Accreditation by TJC is recognized nationwide as a symbol of quality and commitment to meeting certain performance standards. Many state governments require hospitals to be accredited by TJC to receive Medicaid and Medicare reimbursements, underscoring its influence in the healthcare system.
The Complaint Process: How Patients Can Make a Difference
How to File a Complaint
Patients or family members can report safety concerns to TJC through several methods:
Online Submission: The preferred and most direct method is via TJC's online submission form, which allows for timely receipt and review of concerns.
Mail: Complaints can be mailed to the Office of Quality and Patient Safety at The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181.
Fax: Concerns can also be faxed to (630) 792-5636.
It's important to note that TJC focuses on systemic issues related to patient safety and quality of care, rather than individual billing disputes or clinical decisions.
What Happens After a Complaint Is Filed
Upon receiving a complaint, TJC undertakes a thorough review process:
Initial Assessment: TJC reviews the complaint to determine if it falls within their scope and whether the organization in question is accredited by TJC.
Review of Past Complaints and Accreditation History: TJC examines any previous complaints about the organization and its most recent accreditation survey report. Additionally areas of complaints can receive additional focus in subsequent surveys.
Request for Response: The healthcare organization may be asked to provide a written response detailing how they addressed the complaint.
On-Site Evaluation: In cases of serious concern, TJC may conduct an unannounced, on-site evaluation to assess compliance with standards and the effectiveness of corrective actions.
Inclusion in Quality Monitoring: The complaint may be incorporated into TJC's quality monitoring database, which helps track the performance of healthcare organizations over time.
This process ensures that healthcare organizations are held accountable and encourages them to maintain high standards of patient care.
The Accreditation Process: Ensuring Quality and Safety
TJC's accreditation process is designed to evaluate healthcare organizations' compliance with established standards, including CMS Conditions of Participation and promote continuous improvements in care delivery. Patient concerns within an organization and nationally are factors that influence areas of focus and often lead to the setting of national patient safety goals.
Key Components of the Accreditation Survey
Patient-Centered Approach: Surveys focus on actual care processes and patient experiences.
Data-Driven Evaluation: Organizations are assessed based on data related to patient outcomes and quality measures.
Tracer Methodology: Surveyors use tracer methodology to follow a patient's care journey through the organization, identifying strengths and areas for improvement.
System Tracers: These evaluate the organization's systems and processes, such as infection control, medication management, and emergency preparedness.
Education and Best Practices: Surveyors provide guidance and share best practices to help organizations enhance their performance.
Categories Assessed During The Joint Commission Surveys
The Joint Commission evaluates healthcare organizations across multiple core categories during their accreditation surveys. Each category reflects a vital component of quality and safety. Here's why each area matters and how failure to meet these standards can result in compromised care. Complaints and concerns raised to The Joint Commission can focus its triannual review and patient tracers.
1. Patient Rights and Education
Why it matters: Patients have the right to understand their diagnosis, treatment options, prognosis, and to be involved in their care decisions. When patients are informed and empowered, outcomes improve, and satisfaction increases. Patients are not the people things are done to, they are the integral part of the treatment team.
Example: A patient undergoing chemotherapy for cancer wasn’t informed about the potential side effect of neutropenia (low white blood cells), which could make them more vulnerable to infections. Lacking this knowledge, the patient went to a crowded public event during treatment and developed a severe infection. Had the hospital provided proper education, this complication might have been avoided.
Impact: Assessing how well organizations uphold patient rights and communicate health information ensures that care is not only clinically effective but also ethically delivered and patient-centered.
2. Infection Prevention and Control
Why it matters: Preventing infections in healthcare settings is critical to saving lives. Healthcare-associated infections (HAIs), such as surgical site infections or catheter-associated infections, can lead to significant complications and even death.
Example: A hospital with lax hand hygiene protocols experienced a cluster of MRSA infections in the ICU. An internal audit revealed that staff were not consistently following sterilization practices and handwashing guidelines.
Impact: TJC surveys help identify gaps in infection control policies. Ensuring adherence to hand hygiene, sterile procedures, and isolation protocols protects all patients, especially those who are immunocompromised.
3. Medication Management
Why it matters: Medication errors can lead to serious patient harm, including allergic reactions, overdoses, or dangerous drug interactions. Safe medication practices are essential for patient well-being.
Example: A nurse administered insulin to a diabetic patient without checking their blood sugar level. The patient experienced severe hypoglycemia and required emergency intervention. A robust medication management process would require checks like dose confirmation and patient-specific blood glucose verification.
Impact: TJC evaluates medication prescribing, storage, preparation, and administration processes to reduce the risk of adverse drug events.
4. Environment of Care
Why it matters: A safe physical environment supports healing and reduces the risk of accidents and infections.
Example: An elderly patient tripped over clutter in a hospital hallway, fracturing their hip. This could have been prevented through better housekeeping and safety protocols, such as fall risk assessments and keeping walkways clear.
Impact: By ensuring that facilities maintain clean, accessible, and hazard-free environments, patients are less likely to suffer preventable injuries during their stay.
5. Leadership and Governance
Why it matters: Leadership sets the tone for a culture of safety and quality. Effective governance ensures accountability and continuous improvement throughout the organization.
Example: A hospital ignored repeated staff complaints about understaffing in the emergency department. This led to delays in care and an increase in patient deaths. Once reported to leadership during a TJC survey, governance changes were implemented to increase staffing and oversight.
Impact: TJC assesses whether leaders foster a culture of safety, address systemic risks, and support frontline staff in delivering high-quality care.
6. Staff Qualifications and Competency
Why it matters: Healthcare workers must have appropriate education, credentials, and ongoing training to provide competent care.
Example: A newly hired respiratory therapist, lacking proper training in ventilator management, incorrectly adjusted settings on a patient’s machine, leading to respiratory distress.
Impact: TJC reviews hiring practices, credentialing, and ongoing staff competency assessments. This ensures only qualified individuals are involved in patient care.
7. Information Management
Why it matters: In today’s digital age, managing patient information securely and accurately is essential for coordinated, safe, and effective care.
Example: A misfiled lab result in the electronic health record (EHR) system caused a delay in diagnosing a patient’s cancer. The physician, unaware of the abnormal test, continued with routine care.
Impact: TJC evaluates how data is captured, stored, shared, and protected. Proper information management ensures providers have the right information at the right time, reducing errors and improving coordination.
8. Performance Improvement
Why it matters: Healthcare is complex and constantly evolving. Organizations must continually assess their performance and seek opportunities for improvement through continuous quality assurance and improvement efforts.
Example: A hospital noticed a higher-than-average rate of hospital-acquired pressure ulcers. A root cause analysis revealed inconsistent turning schedules for bed-bound patients. As a result, a performance improvement team launched new protocols and training, significantly reducing the incidence.
Impact: By evaluating how organizations monitor outcomes and act on quality data, TJC ensures continuous improvement that benefits patient care.
Why These Standards Matter
These eight categories aren't just checkboxes on a survey, they are the building blocks of safe, reliable, and patient-centered healthcare. They represent the core areas where system breakdowns can lead to errors, and where proactive attention can prevent harm. Care concerns raised by patients and families, provides feedback to our healthcare system on where improvement is needed.
For Patients and Families: Understanding these categories helps you ask better questions and advocate more effectively. For example, if your loved one is hospitalized, you might ask:
“How are medications double-checked here?”
“Can you walk me through the infection prevention practices?”
Patients and families should feel encouraged to provide feedback on the quality of care received. Feedback is critical to understanding where opportunities exist to make care safer.
For Healthcare Organizations: Being held accountable to these standards through Joint Commission surveys not only improves quality but protects patients and enhances trust. Continuing to provide patient and family advocacy resources to address patient concerns is core to robust quality programs. Working with TJC on complaints is an opportunity to gain further insights into opportunities to improve care and what solutions may have been successful in other organizations.
The Power of Patient Tracers
A unique aspect of TJC's survey process is the use of patient tracers. This involves selecting a patient's medical record and tracing their care experience throughout the organization. Surveyors observe care delivery, interview staff, and assess how different departments and services coordinate to meet the patient's needs.
Patient tracers help identify potential safety risks, communication breakdowns, and system inefficiencies. By focusing on real patient experiences, TJC can provide targeted recommendations for improvement.
From Complaints to Standards: Shaping National Patient Safety Goals
TJC's National Patient Safety Goals (NPSGs) are informed by data collected from various sources, including patient complaints, sentinel event reports, and survey findings. These goals address critical areas of concern in healthcare and are updated regularly to reflect emerging issues.
Examples of NPSGs include:
Improving the accuracy of patient identification
Enhancing communication among caregivers
Ensuring the safe use of medications
Reducing the risk of healthcare-associated infections
Preventing mistakes in surgery
Hand hygiene practices
By reporting safety concerns, patients contribute to the development and refinement of these goals, ultimately leading to safer care for everyone.
EvaluCare: Partnering for Patient Safety
EvaluCare partners with healthcare organizations to improve patient safety through a strategy of quality assurance where it reviews care with Eva a Software as a Service that continuously reviews inpatient care.
EvaluCare is also a trusted resource for patients and families seeking to understand potential medical errors by evaluating medical care for care quality when error occur. With a team of quality and medical experts,
EvaluCare team members as healthcare insiders and leaders partner with TJC on surveys and quality improvement initiatives.
Together, we can make care safer and support meaningful improvements in quality.
Taking Action: Your Role in Improving Healthcare
If you believe you or a loved one has been harmed due to unsafe care, reporting your concerns to The Joint Commission can be a powerful step toward accountability and improvement. Your actions not only address your individual experience but also contribute to a safer healthcare system for all.
If your concern has not been addressed by the healthcare organization you received care from, you can find more information on filing a complaint, at The Joint Commission's official page:
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Eva, EvaluCare’s AI-powered SaaS, delivers quality review for inpatient care by checking adherence to thousands of evidence-based guidelines and protocols. It identifies care gaps, routes clear actions to the right clinicians, and accelerates improvement cycles, strengthening documentation and coding while reducing HACs, HAIs readmissions, length of stay and more. The result is an ROI, starting in the seven figures even for critical access hospitals. Learn more at evalucare.net or contact info@evalucare.net.
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About the Author
Jason Minor is a healthcare quality and transformation leader with nearly 30 years of continuous improvement experience. A Certified Lean Six Sigma Black Belt, Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, and Certified Utilization Review Professional, he has led thousands of end‑to‑end improvement projects, mentored dozens of quality professionals, and pioneered healthcare SaaS innovations.
As Board Chair of the Vermont Program for Quality in Health Care, Jason has partnered with hospitals, non‑profits, and state agencies to elevate patient safety and care quality statewide. Previously, as Network Vice President of Quality at the UVM Health Network and through the Jeffords Institute for Quality, he guided the redesign of a system‑wide quality framework and led initiatives that achieved a number‑one patient safety ranking among the nation’s top academic medical centers.
In 2020, Jason founded EvaluCare to help organizations shift from episodic improvement to a robust quality assurance approach.
EvaluCare’s Eva platform leverages AI‑powered natural language processing, machine learning, and agentic orchestration to analyze and improve inpatient care and support comprehensive quality, mortality, peer, and utilization reviews.
Jason Minor, EvaluCare Executive Director
Network Director Continuous Systems Improvement Jeffords Institute for Quality UVM Health
Board Chair Vermont Program for Quality in Health Care Inc.,
Vice Chair Northwestern Counseling & Support Services, Inc
Lecturer UVM College of Nursing & Health Sciences in Healthcare Quality
Quality Peer Reviewer Vermont Care Partners: Centers of Excellence
