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Sentinel Event Updates

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Sentinel Event

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Sentinel Event Alerts, statistics, (Updated for 2Q 2012) forms and tools, FAQs and more.

Related Items: Sentinel Event , Sentinel Event Alert

04/02/2014
Topics Library

Facts about patient safety

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The Joint Commission is committed to improving healthcare safety. This commitment is inherent in its mission to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe. . .

Related Items: Fact Sheets , National Patient Safety Goals , Patient Safety , Sentinel Event , Speak Up , Universal Protocol , Patient Safety Fact Sheets

02/03/2014
Topics Library

Sentinel Event Alert Issue 51: Preventing unintended retained foreign objects

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The unintended retention of foreign objects (URFOs) – also called retained surgical items (RSIs) – after invasive procedures can cause death, and surviving patients may sustain both physical and emotional harm, depending on the type of object retained and the length of time it is retained.

Related Items: Ambulatory Health Care , Critical Access Hospital , Hospital , Office-Based Surgery , Sentinel Event , Sentinel Event Alert , Webinar

10/17/2013
Blog

Preventing suicide among ED patients – a realizable goal

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An immediately recognizable unnecessary death in an ED is a suicide that was initiated in the ED itself. These suicides need not occur if suicidal patients are recognized, appropriate immediate protective interventions are put in place, and the patients are successfully transitioned to definitive treatment, whether inpatient or outpatient.

Related Items: Suicide , Sentinel Event Alert , Sentinel Event , Physician , Blog

10/16/2013
News

Joint Commission Awarded ONC Health IT Contract

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Today, The Joint Commission announced that it has received a sole source contract from the federal Office of the National Coordinator for Health Information Technology (ONC) to address one of the key recommendations made in the Institute of Medicine report, “Health IT and Patient Safety: Building Safer Systems for Better Care.”

Related Items: Health Information Technology , Patient Safety , Sentinel Event , News Releases

07/02/2013
News

New “Take 5 with The Joint Commission” Podcast Series Offers Fresh Perspective on Health Care Topics

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Health care professionals and others interested in improving health care quality and safety have a new resource — the “Take 5” podcast series from The Joint Commission, a series of casual conversations on health care topics.

Related Items: Podcast , Sentinel Event , News Releases

04/22/2013
Topics Library

Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals

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Many medical devices have alarm systems. These alarm-equipped devices are essential to providing safe care to patients in many health care settings; clinicians depend on these devices for information they need to deliver appropriate care and to guide treatment decisions.

Related Items: Critical Access Hospital , Hospital , Sentinel Event , Sentinel Event Alert , Webinar

04/08/2013
Topics Library

Sentinel Event Policy Expanded Beyond Patients

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Joint Commission Requirement

Related Items: Sentinel Event , 2012 Joint Commission Requirement

12/01/2012
News

Joint Commission Issues New Sentinel Event Alert: Safe Use of Opioids in Hospitals

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Although hospital patients may need the strong pain relief that only opioids can provide, a Sentinel Event Alert issued today by The Joint Commission urges hospitals to take specific steps to prevent serious complications or even deaths from opioid use.

Related Items: Sentinel Event Alert , Pain Management , News Releases , Sentinel Event , Opioids

08/08/2012
Topics Library

Sentinel Event Alert Issue 49: Safe use of opioids in hospitals

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Although hospital patients may need the strong pain relief that only opioids can provide, The Joint Commission urges hospitals to take specific steps to prevent serious complications or even deaths from opioid use.

Related Items: Newsletter , Sentinel Event , Sentinel Event Alert , Pain Management , Opioids

08/08/2012
Topics Library

Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety

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The link between health care worker fatigue and adverse events is well documented, with a substantial number of studies indicating that the practice of extended work hours contributes to high levels of worker fatigue and reduced productivity.

Related Items: Newsletter , Patient Safety , Sentinel Event , Sentinel Event Alert , Fatigue

12/14/2011
Topics Library

Sentinel Event Alert, Issue 47: Radiation risks of diagnostic imaging

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Diagnostic radiation is an effective tool that can save lives. The higher the dose of radiation delivered at any one time, however, the greater the risk for long-term damage. If a patient receives repeated doses, harm can also occur as the cumulative effect of those multiple doses over time.

Related Items: Ambulatory Health Care , Critical Access Hospital , Hospital , Radiation Overdose , Sentinel Event , Sentinel Event Alert

09/01/2011
Topics Library

Sentinel Event Alert, Issue 46: A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department

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In 1998, The Joint Commission issued a Sentinel Event Alert on preventing inpatient suicides; this Alert updates the prevention strategies presented in that Alert with a focus on general hospitals and prevention of suicide in medical/surgical units and the emergency department.

Related Items: Sentinel Event , Sentinel Event Alert

11/17/2010
Topics Library

Sentinel Event Alert, Issue 45: Preventing violence in the health care setting

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Once considered safe havens, health care institutions today are confronting steadily increasing rates of crime, including violent crimes such as assault, rape and homicide.

Related Items: Ambulatory Health Care , Behavioral Health Care , Critical Access Hospital , Hospital , Sentinel Event , Sentinel Event Alert

06/03/2010
Topics Library

Sentinel Event Alert, Issue 44: Preventing Maternal Death

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The goal of all labor and delivery units is a safe birth for both newborn and mother. A previous Alert reviewed the causes of death and injury among newborns with normal birth weight and suggested

Related Items: Sentinel Event , Sentinel Event Alert

01/26/2010
Topics Library

Sentinel Event Alert, Issue 43: Leadership committed to safety

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Leadership is a critical function in promoting high quality, safe health care. In health care organizations, leadership is provided by the governing body, the chief executive and...

Related Items: Ambulatory Health Care , Behavioral Health Care , Critical Access Hospital , Home Care , Hospital , Laboratory Services , Nursing Care Center , Sentinel Event , Sentinel Event Alert

08/27/2009
Topics Library

Affirmation Statement

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Completed by accredited organizations, ONLY when an Alternative 4 review in response to a sentinel event is chosen.

Related Items: Behavioral Health Care , Sentinel Event

04/01/2009
Topics Library

Alternatives for Sharing Sentinel Event-Related Information with The Joint Commission

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The Sentinel Event Policy requests the organization to transmit its root cause analysis, action plan, and other sentinel event-related information to The Joint Commission electronically.

Related Items: Sentinel Event

04/01/2009
Topics Library

Sentinel Event Alert, Issue 42: Safely implementing health information and converging technologies

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As health information technology (HIT) and “converging technologies”—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations.

Related Items: Ambulatory Health Care , Behavioral Health Care , Critical Access Hospital , Home Care , Hospital , Laboratory Services , Nursing Care Center , Sentinel Event , Sentinel Event Alert

12/11/2008
Topics Library

Sentinel Event Alert, Issue 41: Preventing errors relating to commonly used anticoagulants

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Reports of accidental deaths and overdosing due to the improper use of anticoagulant drugs have received significant public attention.

Related Items: Ambulatory Health Care , Critical Access Hospital , Home Care , Hospital , Nursing Care Center , Sentinel Event , Sentinel Event Alert

09/24/2008
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