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Sentinel Event Alert
Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.
Accredited organizations should consider information in an Alert when designing or redesigning relevant processes and consider implementing relevant suggestions or reasonable alternatives.
Please route issues to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to The Joint Commission.
Click here to receive an e-mail notification for future Sentinel Event Alerts.
Joint Commission Resources
Click here for JCR content in support of Sentinel Event Alerts
Index of Issues
| Issue 42 - December 11, 2008: Safely implementing health information and converging technologies | Dec 10, 2008 |
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| Issue 41 - September 24, 2008: Preventing errors relating to commonly used anticoagulants | Sep 23, 2008 |
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| Issue 40 - July 9, 2008: Behaviors that undermine a culture of safety | Jul 02, 2008 |
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| Issue 39 - April 11, 2008: Preventing pediatric medication errors | Apr 09, 2008 |
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| Issue 38 - February 14, 2008: Preventing accidents and injuries in the MRI suite | Feb 13, 2008 |
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| Issue 37 - September 6, 2006: Preventing adverse events caused by emergency electrical power system failures | Sep 05, 2006 |
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| Issue 36 - April 3, 2006: Tubing misconnections—a persistent and potentially deadly occurrence | Mar 27, 2006 |
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| Issue 35 - January 25, 2006: Using medication reconciliation to prevent errors | Jan 25, 2006 |
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| Issue 34 - July 14, 2005: Preventing vincristine administration errors | Jul 14, 2005 |
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| Issue 33 - December 20, 2004: Patient controlled analgesia by proxy | Dec 20, 2004 |
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| Issue 32 - October 6, 2004: Preventing, and managing the impact of, anesthesia awareness | Oct 06, 2004 |
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| Issue 31 - August 31, 2004: Revised guidance to help prevent kernicterus | Aug 31, 2004 |
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| Issue 30 - July 21, 2004: Preventing infant death and injury during delivery | Jul 21, 2004 |
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| Issue 29 - June 24, 2003: Preventing surgical fires | Jun 24, 2003 |
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| Issue 28 - January 22, 2003: Infection control related sentinel events | Jan 22, 2003 |
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| Issue 27 - September 6, 2002: Bed rail-related entrapment deaths | Sep 06, 2002 |
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| Issue 26 - June 17, 2002: Delays in treatment | Jun 17, 2002 |
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| Issue 25 - February 26, 2002: Preventing ventilator-related deaths and injuries | Feb 26, 2002 |
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| Issue 24 - December 5, 2001: A follow-up review of wrong site surgery | Dec 05, 2001 |
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| Issue 23 - September 1, 2001: Medication errors related to potentially dangerous abbreviations | Sep 01, 2001 |
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| Issue 22 - August 1, 2001: Preventing needlestick and sharps injuries | Aug 01, 2001 |
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| Issue 21 - July 1, 2001: Medical gas mix-ups | Jul 01, 2001 |
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| Issue 20 - June 1, 2001: Exposure to Creutzfeldt-Jakob Disease | Jun 01, 2001 |
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| Issue 19 May 1, 2001: Look-alike, sound-alike drug names | May 01, 2001 |
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| Issue 18 - April 1, 2001: Kernicterus threatens healthy newborns | Apr 01, 2001 |
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| Issue 17 - March 1, 2001: Lessons Learned: Fires in the Home Care Setting | Mar 01, 2001 |
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| Issue 16 - February 27, 2001: Mix-up Leads to a Medication Error | Feb 27, 2001 |
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| Issue 15 - November 30, 2000: Infusion Pumps: Preventing Future Adverse Events | Nov 30, 2000 |
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| Issue 14 - July 12, 2000: Fatal Falls: Lessons for the Future | Jul 12, 2000 |
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| Issue 13 - April 21, 2000: Making an Impact on Health Care | Apr 21, 2000 |
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| Issue 12 - February 4, 2000: Operative and Post-Operative Complications: Lessons for the Future | Feb 04, 2000 |
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| Issue 11 - November 19, 1999: High-Alert Medications and Patient Safety | Nov 19, 1999 |
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| Issue 10 - August 30, 1999: Blood Transfusion Errors: Preventing Future Occurrences | Aug 30, 1999 |
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| Issue 9 - April 9, 1999: Infant Abductions: Preventing Future Occurrences | Apr 09, 1999 |
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| Issue 8 - November 18, 1998: Preventing Restraint Deaths | Nov 18, 1998 |
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| Issue 7 - November 6, 1998: Inpatient Suicides: Recommendations for Prevention | Nov 06, 1998 |
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| Issue 6 - August 28, 1998: Lessons Learned: Wrong Site Surgery | Aug 28, 1998 |
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| Issue 5 - July 24, 1998: Board Votes To Increase Time Frame For Submitting Root Cause Analysis | Jul 24, 1998 |
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| Issue 4 - May 11, 1998: Examples Of Voluntarily Reportable Sentinel Events | May 11, 1998 |
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| Issue 3 - May 1, 1998: Board of Commissioners Affirms Support For Sentinel Event Policy | May 01, 1998 |
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| Issue 2 - March 20, 1998: Board To Review Modifications To Sentinel Event Procedures | Mar 20, 1998 |
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| Issue 1 - February 28, 1998: New Publication | Feb 28, 1998 |
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