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Wednesday 10:46 CST, October 22, 2014

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Sentinel Event Updates

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Topics Library

Facts about patient safety

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As part of its mission, The Joint Commission is committed to improving health care safety for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

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

10/21/2014
Content Page

Sentinel Event

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

Related Items: Sentinel Event Alert , Sentinel Event

08/29/2014
Topics Library

Why Organizations Self Report Sentinel Events to The Joint Commission

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This article, first published in the September 2014 issue of Joint Commission Perspectives, explores the benefits to organizations of working through the sentinel event process and how it improves patient safety.

Related Items: Ambulatory Health Care , Behavioral Health Care , Critical Access Hospital , Disease-Specific Care , Health Care Staffing , Home Care , Hospital , Laboratory Accreditation Program , Nursing Care Center , Resource , Sentinel Event

08/29/2014
Topics Library

Sentinel Event Alert 53: Managing risk during transition to new ISO tubing connector standards

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Tubing misconnections continue to cause severe patient injury and death, since tubes with different functions can easily be connected using luer connectors, or connections can be “rigged” (constructed) using adapters, tubing or catheters.

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

08/20/2014
Blog

Don’t make me wait!

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People hate to wait. They don’t like waiting in line for their coffee. They don’t like waiting to find out the latest gossip. They don’t even like waiting for water to boil. Now imagine how much people hate to wait for something in which the time frame is critical – even potentially life threatening, if delayed. Unfortunately, it happens in health care far too often.

Related Items: Blog , Physician , Sentinel Event

07/02/2014
News

The Joint Commission Alerts Health Care Industry to Prevalence of Unsafe Injection Practices

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The Joint Commission alerts health care industry to prevalence of unsafe injection practices.

Related Items: News Releases , Sentinel Event

06/16/2014
Topics Library

Sentinel Event Alert Issue 52: Preventing infection from the misuse of vials

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Thousands of patients have been adversely affected by the misuse of single-dose/single-use and multiple-dose vials. Webinar replay information added September 2014.

Related Items: Sentinel Event , Sentinel Event Alert

06/16/2014
Topics Library

Facts about the Patient Safety Advisory Group

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In April 2002, The Joint Commission appointed a panel of widely recognized patient safety experts to advise it on the development of Sentinel Event Alert, The Joint Commission’s patient safety newsletter. At that time, the panel was named the Sentinel Event Advisory Group.

Related Items: National Patient Safety Goals , Patient Safety , Sentinel Event , Patient Safety Fact Sheets , Advisory Group Fact Sheets

01/10/2014
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
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 Accreditation Program , Nursing Care Center , Sentinel Event , Sentinel Event Alert

08/27/2009
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