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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.
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Joint Commission Resources
JCR content in support of Sentinel Event Alerts
Index of Issues
| Issue 43: Leadership committed to safety | Aug 27, 2009 |
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| Issue 42: Safely implementing health information and converging technologies | Dec 11, 2008 |
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| Issue 41: Preventing errors relating to commonly used anticoagulants | Sep 24, 2008 |
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| Issue 40: Behaviors that undermine a culture of safety | Jul 09, 2008 |
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| Issue 39: Preventing pediatric medication errors | Apr 11, 2008 |
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| Issue 38: Preventing accidents and injuries in the MRI suite | Feb 14, 2008 |
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| Issue 37: Preventing adverse events caused by emergency electrical power system failures | Sep 06, 2006 |
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| Issue 36: Tubing misconnections—a persistent and potentially deadly occurrence | Apr 03, 2006 |
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| Issue 35: Using medication reconciliation to prevent errors | Jan 25, 2006 |
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| Issue 34: Preventing vincristine administration errors | Jul 14, 2005 |
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| Issue 33: Patient controlled analgesia by proxy | Dec 20, 2004 |
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| Issue 32: Preventing, and managing the impact of, anesthesia awareness | Oct 06, 2004 |
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| Issue 31: Revised guidance to help prevent kernicterus | Aug 31, 2004 |
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| Issue 30: Preventing infant death and injury during delivery | Jul 21, 2004 |
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| Issue 29: Preventing surgical fires | Jun 24, 2003 |
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| Issue 28: Infection control related sentinel events | Jan 22, 2003 |
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| Issue 27: Bed rail-related entrapment deaths | Sep 06, 2002 |
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| Issue 26: Delays in treatment | Jun 17, 2002 |
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| Issue 25: Preventing ventilator-related deaths and injuries | Feb 26, 2002 |
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| Issue 24: A follow-up review of wrong site surgery | Dec 05, 2001 |
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| Issue 23: Medication errors related to potentially dangerous abbreviations | Sep 01, 2001 |
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| Issue 22: Preventing needlestick and sharps injuries | Aug 01, 2001 |
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| Issue 21: Medical gas mix-ups | Jul 01, 2001 |
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| Issue 20: Exposure to Creutzfeldt-Jakob Disease | Jun 01, 2001 |
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| Issue 19: Look-alike, sound-alike drug names | May 01, 2001 |
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| Issue 18: Kernicterus threatens healthy newborns | Apr 01, 2001 |
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| Issue 17: Lessons Learned: Fires in the Home Care Setting | Mar 01, 2001 |
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| Issue 16: Mix-up Leads to a Medication Error | Feb 27, 2001 |
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| Issue 15: Infusion Pumps: Preventing Future Adverse Events | Nov 30, 2000 |
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| Issue 14: Fatal Falls: Lessons for the Future | Jul 12, 2000 |
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| Issue 13: Making an Impact on Health Care | Apr 21, 2000 |
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| Issue 12: Operative and Post-Operative Complications: Lessons for the Future | Feb 04, 2000 |
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| Issue 11: High-Alert Medications and Patient Safety | Nov 19, 1999 |
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| Issue 10: Blood Transfusion Errors: Preventing Future Occurrences | Aug 30, 1999 |
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| Issue 9: Infant Abductions: Preventing Future Occurrences | Apr 09, 1999 |
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| Issue 8: Preventing Restraint Deaths | Nov 18, 1998 |
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| Issue 7: Inpatient Suicides: Recommendations for Prevention | Nov 06, 1998 |
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| Issue 6: Lessons Learned: Wrong Site Surgery | Aug 28, 1998 |
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| Issue 5: Board Votes To Increase Time Frame For Submitting Root Cause Analysis | Jul 24, 1998 |
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| Issue 4: Examples Of Voluntarily Reportable Sentinel Events | May 11, 1998 |
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| Issue 3: Board of Commissioners Affirms Support For Sentinel Event Policy | May 01, 1998 |
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| Issue 2: Board To Review Modifications To Sentinel Event Procedures | Mar 20, 1998 |
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| Issue 1: New Publication | Feb 28, 1998 |
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