http://www.jointcommission.orgJoint Commissionhttp://www.jointcommission.org//sea_issue_50/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. Unknown AuthorMon, 08 Apr 2013 06:50:00 GMThttp://www.jointcommission.org//sea_issue_49/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. Unknown AuthorWed, 08 Aug 2012 08:00:00 GMThttp://www.jointcommission.org//sea_issue_48/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.Unknown AuthorWed, 14 Dec 2011 08:42:00 GMThttp://www.jointcommission.org//sea_issue_47/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.Unknown AuthorThu, 01 Sep 2011 10:00:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_46_a_follow-up_report_on_preventing_suicide_focus_on_medicalsurgical_units_and_the_emergency_department/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.Unknown AuthorWed, 17 Nov 2010 15:58:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_45_preventing_violence_in_the_health_care_setting_/Once considered safe havens, health care institutions today are confronting steadily increasing rates of crime, including violent crimes such as assault, rape and homicide. Unknown AuthorThu, 03 Jun 2010 13:15:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_44_preventing_maternal_death/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 Unknown AuthorTue, 26 Jan 2010 13:11:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_43_leadership_committed_to_safety/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...Unknown AuthorThu, 27 Aug 2009 13:08:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_42_safely_implementing_health_information_and_converging_technologies/As health information technology (HIT) and “converging technologies”—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations.Unknown AuthorThu, 11 Dec 2008 13:03:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_41_preventing_errors_relating_to_commonly_used_anticoagulants/Reports of accidental deaths and overdosing due to the improper use of anticoagulant drugs have received significant public attention. Unknown AuthorWed, 24 Sep 2008 12:55:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and...Unknown AuthorWed, 09 Jul 2008 12:08:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_39_preventing_pediatric_medication_errors/Errors associated with medications are believed to be the most common type of medical error and are a significant cause of preventable adverse events. Unknown AuthorFri, 11 Apr 2008 12:06:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_38_preventing_accidents_and_injuries_in_the_mri_suite/Magnetic resonance imaging (MRI) was applied to health care in the late 1970s to provide never-before-seen two- and three-dimensional views of body tissue and structure.Unknown AuthorThu, 14 Feb 2008 12:05:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_37_preventing_adverse_events_caused_by_emergency_electrical_power_system_failures/Health care facilities are highly dependent on reliable sources of electrical power. Unknown AuthorWed, 06 Sep 2006 12:03:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_36_tubing_misconnections—a_persistent_and_potentially_deadly_occurrence/Tubing and catheter misconnection errors are an important and under-reported problem in health care organizations. Unknown AuthorMon, 03 Apr 2006 12:01:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. Unknown AuthorWed, 25 Jan 2006 11:59:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_34_preventing_vincristine_administration_errors/Despite repeated warnings over the years and extensive labeling requirements and standards, tragic errors related to the inadvertent administration of vincristine intrathecally...Unknown AuthorThu, 14 Jul 2005 11:48:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_33_patient_controlled_analgesia_by_proxy/Patient controlled analgesia (PCA) is an effective and efficient method of controlling pain, and when it is used as prescribed and intended, the risk of oversedation is significantly reduced.Unknown AuthorMon, 20 Dec 2004 11:46:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_32_preventing_and_managing_the_impact_of_anesthesia_awareness/Anesthesia awareness, also called unintended intraoperative awareness, occurs under general anesthesia when a patient becomes cognizant of some or all events during surgery or a procedure, and...Unknown AuthorWed, 06 Oct 2004 11:44:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_31_revised_guidance_to_help_prevent_kernicterus/Issue 18, published in April 2001, of Sentinel Event Alert discussed the risk factors, root causes, risk reduction strategies and follow up recommendations to guide health care organizations...Unknown AuthorTue, 31 Aug 2004 11:42:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_30_preventing_infant_death_and_injury_during_delivery/While a healthy and safe birth for the mother and infant is the goal for all labor and delivery units—regardless of the level of services available—in some instances, what should be a joyous...Unknown AuthorWed, 21 Jul 2004 11:39:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_29_preventing_surgical_fires/In the fire triangle—heat, fuel and oxygen—each element must be present for a fire to start. And, though the incidents are significantly under-reported, too often all three elements come together...Unknown AuthorTue, 24 Jun 2003 11:37:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_28_infection_control_related_sentinel_events/Despite the small number of infection-related sentinel event cases reported to the Joint Commission, the number of patients acquiring infections in the health care setting, as well as the number...Unknown AuthorWed, 22 Jan 2003 11:35:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_27_bed_rail-related_entrapment_deaths/Since 1995, the Joint Commission has received reports of seven deaths or injuries related to bed rails; three of these reports were from hospitals, two were from long term care facilities, one was...Unknown AuthorFri, 06 Sep 2002 11:33:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_26_delays_in_treatment/While hospital Emergency Departments (EDs) are the source of just over one-half of all reported sentinel event cases of patient death or permanent injury due to delays in treatment...Unknown AuthorMon, 17 Jun 2002 11:30:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_25_preventing_ventilator-related_deaths_and_injuries/As of January 2002, the Joint Commission has reviewed 23 reports of deaths or injuries related to long term ventilation--19 events resulted in death and four in coma. Unknown AuthorTue, 26 Feb 2002 11:28:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_24_a_follow-up_review_of_wrong_site_surgery/In August 1998, the Joint Commission issued a Sentinel Event Alert examining the problem of wrong site surgery, including a review of 15 cases that had been reported to JCAHO.Unknown AuthorWed, 05 Dec 2001 11:23:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_23_medication_errors_related_to_potentially_dangerous_abbreviations/One of the major causes of medication errors is the ongoing use of potentially dangerous abbreviations and dose expressions. Unknown AuthorSat, 01 Sep 2001 11:21:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_22_preventing_needlestick_and_sharps_injuries/Health care workers are exposed to a wide range of hazards in the workplace, especially hazards associated with medical equipment. Unknown AuthorWed, 01 Aug 2001 11:10:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_21_medical_gas_mix-ups/The Joint Commission received two reports of medical gas mix-ups in 2000 that resulted in the death of four patients and injury to five patients. Unknown AuthorSun, 01 Jul 2001 11:07:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_20_exposure_to_creutzfeldt-jakob_disease/Within the last year, the Joint Commission has received reports of two separate incidents at accredited hospitals where patients--a total of 14--may have been exposed to Creutzfeldt-Jakob Disease...Unknown AuthorFri, 01 Jun 2001 11:05:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_19_look-alike_sound-alike_drug_names/Since the initial publication of the Joint Commission's Sentinel Event Alert in 1998, several issues have been devoted to the topic of medication errors and the identification, prevention, and...Unknown AuthorTue, 01 May 2001 11:03:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_18_kernicterus_threatens_healthy_newborns/Kernicterus is a condition of newborns that leads to severely disabling brain damage or death. It results from hyperbilirubinemia that can be caused by a number of factors. Unknown AuthorSun, 01 Apr 2001 10:59:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_17_lessons_learned_fires_in_the_home_care_setting/Since April 1997, 11 sentinel events have been received and reviewed by the Joint Commission related to home health care patients who were either injured or killed as a result of a fire in the home. Unknown AuthorThu, 01 Mar 2001 10:57:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_16_mix-up_leads_to_a_medication_error/Recently, the Joint Commission's Board of Commissioners approved new and revised standards directly focused on patient safety and medical/health care error reduction in hospitals. Unknown AuthorTue, 27 Feb 2001 10:55:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_15_infusion_pumps_preventing_future_adverse_events/Mishaps involving the use of infusion pumps have led to deaths and near-fatal drug overdoses in health care organizations nationwide. Unknown AuthorThu, 30 Nov 2000 10:53:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_14_fatal_falls_lessons_for_the_future/Health care organizations that have experienced sentinel events due to falls have identified the root causes and risk reduction strategies included in this issue. Unknown AuthorWed, 12 Jul 2000 10:51:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_13_making_an_impact_on_health_care_/Sentinel Event Alert was first published in February 1998 to provide important information relating to the occurrence and management of sentinel events in Joint Commission accredited health care...Unknown AuthorFri, 21 Apr 2000 10:48:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_12_operative_and_post-operative_complications_lessons_for_the_future/Since the Joint Commission began tracking sentinel events nearly four years ago, the Accreditation Committee has reviewed 64 cases related to operative and post-operative complications.Unknown AuthorFri, 04 Feb 2000 10:38:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_11_high-alert_medications_and_patient_safety/Since the Joint Commission began tracking sentinel events in 1995, the Accreditation Committee of the Joint Commission's Board of Commissioners has reviewed 89 cases related to medication errors.Unknown AuthorFri, 19 Nov 1999 10:36:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_10_blood_transfusion_errors_preventing_future_occurrences/Since the Joint Commission began tracking sentinel events more than three years ago, the Accreditation Committee has reviewed 12 cases related to transfusion errors. Unknown AuthorMon, 30 Aug 1999 10:32:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_9_infant_abductions_preventing_future_occurrences/Since the Joint Commission began tracking sentinel events three years ago, the Accreditation Committee has reviewed eight cases related to infant abductions. Unknown AuthorFri, 09 Apr 1999 10:28:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_8_preventing_restraint_deaths/Since the Joint Commission began tracking sentinel events two years ago, the Accreditation Committee has reviewed 20 cases related to deaths of patients who were being physically restrained. Unknown AuthorWed, 18 Nov 1998 10:20:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_7_inpatient_suicides_recommendations_for_prevention/Since the Joint Commission enacted its Sentinel Event Policy two years ago, the Accreditation Committee has reviewed 65 cases related to inpatient suicides.​Unknown AuthorFri, 06 Nov 1998 10:11:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_6_lessons_learned_wrong_site_surgery/Since the Joint Commission's Sentinel Event Policy was first introduced two years ago, the Accreditation Committee has reviewed 15 cases related to surgery at the wrong site.Unknown AuthorFri, 28 Aug 1998 10:04:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_5_board_votes_to_increase_time_frame_for_submitting_root_cause_analysis/Board Votes To Increase Time Frame For Submitting Root Cause AnalysisUnknown AuthorFri, 24 Jul 1998 09:56:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_4_examples_of_voluntarily_reportable_sentinel_events/Board approved examples of Voluntarily Reportable Sentinel Events.Unknown AuthorMon, 11 May 1998 07:38:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_3_board_of_commissioners_affirms_support_for_sentinel_event_policy/The Board affirmed its support for the Sentinel Event Policy and underscored the need for organizations to conduct root cause analyses of sentinel events.​Unknown AuthorFri, 01 May 1998 07:23:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_2_board_to_review_modifications_to_sentinel_event_procedures/At its April 24-25 meeting, the Joint Commission's Board of Commissioners will address modifications to the procedures relating to implementation of the Sentinel Event Policy.Unknown AuthorFri, 20 Mar 1998 07:13:00 GMThttp://www.jointcommission.org//sentinel_event_alert_issue_1_new_publication_/The first issue of Sentinel Event Alert, a periodic publication dedicated to providing important information relating to the occurrence and management of sentinel events.Unknown AuthorSat, 28 Feb 1998 07:02:00 GMT