Joint Commission Topic Library

Hospitals, Critical Access Hospitals

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

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.

04/08/2013

Hospitals, Critical Access Hospitals

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

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.

08/08/2012

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Laboratory Services, Nursing and Rehabilitation Center, Health Care Staffing Services

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

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.

12/14/2011

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Office-Based Surgery

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

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.

09/01/2011

Hospitals, Critical Access Hospitals

Sentinel Event Alert, Issue 46: A follow-up report on preventing suicide: Focus on medical/surgical 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.

Related Topics: Sentinel Event, Sentinel Event Alert

11/17/2010

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Behavioral Health Care, Nursing and Rehabilitation Center, Office-Based Surgery

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.

06/03/2010

Hospitals, Critical Access Hospitals

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

Related Topics: Sentinel Event Alert, Sentinel Event

01/26/2010

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Behavioral Health Care, Laboratory Services, Nursing and Rehabilitation Center, Office-Based Surgery, Home Care

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...

08/27/2009

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Behavioral Health Care, Laboratory Services, Nursing and Rehabilitation Center, Office-Based Surgery, Home Care

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.

12/11/2008

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Nursing and Rehabilitation Center, Home Care

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.

09/24/2008

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Behavioral Health Care, Laboratory Services, Nursing and Rehabilitation Center, Office-Based Surgery, Home Care

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...

07/09/2008

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Nursing and Rehabilitation Center, Home Care

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.

04/11/2008

Ambulatory Health Care, Hospitals, Critical Access Hospitals

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.

Related Topics: Sentinel Event Alert, Sentinel Event

02/14/2008

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Nursing and Rehabilitation Center, Office-Based Surgery

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.

Related Topics: Sentinel Event, Sentinel Event Alert

09/06/2006

Hospitals, Critical Access Hospitals, Nursing and Rehabilitation Center, Home Care

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.

Related Topics: Sentinel Event Alert, Sentinel Event

04/03/2006

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Nursing and Rehabilitation Center, Office-Based Surgery, Home Care

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.

01/25/2006

Hospitals, Critical Access Hospitals

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...

Related Topics: Sentinel Event Alert, Sentinel Event

07/14/2005

Hospitals, Critical Access Hospitals

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.

12/20/2004

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Office-Based Surgery

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...

10/06/2004

Hospitals, Critical Access Hospitals

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...

Related Topics: Sentinel Event, Sentinel Event Alert

08/31/2004

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...

Related Topics: Sentinel Event Alert, Sentinel Event

07/21/2004

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Office-Based Surgery

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...

Related Topics: Sentinel Event, Sentinel Event Alert

06/24/2003

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Laboratory Services, Nursing and Rehabilitation Center, Office-Based Surgery, Home Care, Disease-Specific Care

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...

01/22/2003

Hospitals, Critical Access Hospitals, Nursing and Rehabilitation Center

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...

Related Topics: Sentinel Event, Sentinel Event Alert

09/06/2002

Hospitals, Critical Access Hospitals, Home Care

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...

Related Topics: Sentinel Event Alert, Sentinel Event

06/17/2002

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

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

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

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

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

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

Sentinel Event Alert, Issue 44: Preventing Maternal Death

Sentinel Event Alert, Issue 43: Leadership committed to safety

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

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

Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety

Sentinel Event Alert, Issue 39: Preventing pediatric medication errors

Sentinel Event Alert, Issue 38: Preventing accidents and injuries in the MRI suite

Sentinel Event Alert, Issue 37: Preventing adverse events caused by emergency electrical power system failures

Sentinel Event Alert, Issue 36: Tubing misconnections—a persistent and potentially deadly occurrence

Sentinel Event Alert, Issue 35: Using medication reconciliation to prevent errors

Sentinel Event Alert, Issue 34: Preventing vincristine administration errors

Sentinel Event Alert, Issue 33: Patient controlled analgesia by proxy

Sentinel Event Alert, Issue 32: Preventing, and managing the impact of, anesthesia awareness

Sentinel Event Alert, Issue 31: Revised guidance to help prevent kernicterus

Sentinel Event Alert, Issue 30: Preventing infant death and injury during delivery

Sentinel Event Alert, Issue 29: Preventing surgical fires

Sentinel Event Alert, Issue 28: Infection control related sentinel events

Sentinel Event Alert, Issue 27: Bed rail-related entrapment deaths

Sentinel Event Alert, Issue 26: Delays in treatment