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Saturday 6:09 CST, July 23, 2016

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Sentinel Event Alert/Topics Library Updates

Most Recent
Topics Library

Sentinel Event Alert 56: Detecting and treating suicide ideation in all settings

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The rate of suicide is increasing in America. Now the 10th leading cause of death, suicide claims more lives than traffic accidents and more than twice as many as homicides. Access the Alert, a downloadable Infographic, and a document of related Joint Commission standards.

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 , Sentinel Event , Sentinel Event Alert , Suicide , Palliative Care , Integrated Care Certification , Patient Blood Management Certification

02/24/2016
Topics Library

Sentinel Event Alert 55: Preventing falls and fall-related injuries in health care facilities

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Falls resulting in injury are a prevalent patient safety problem. Elderly and frail patients with fall risk factors are not the only ones who are vulnerable to falling in health care facilities.

Related Items: Falls , Sentinel Event Alert

09/28/2015
Topics Library

Sentinel Event Alert 54: Safe use of health information technology

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Health information technology (health IT) is rapidly evolving and its use is growing, presenting new challenges to health care organizations. A Safe Health IT webinar replay and slide presentation from June 11, 2015 are now available. We hope that you find this information helpful and pass it on.

Related Items: Sentinel Event Alert , Safe Health IT

03/31/2015
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. 12/3/14 Webinar replayand slides added.

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

08/20/2014
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 , Infection Prevention and HAIs , Sentinel Event Infection

06/16/2014
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
Topics Library

Addendum to Sentinel Event Alert Issue 20: Exposure to Creutzfeldt-Jakob Disease

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In this addendum, The Joint Commission clarifies the recommendations in Sentinel Event Alert #20: Exposure to Creutzfeldt-Jakob Disease (CJD) regarding the recommended practice of quarantining equipment.

Related Items: Sentinel Event Alert , Infection Prevention and HAIs , Sentinel Event Infection

09/18/2013
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 , Infographic

04/08/2013
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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This Sentinel Event Alert has been retired. It has been replaced with Sentinel Event Alert #56: Detecting and treating suicide ideation in all settings.

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
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 Accreditation Program , Nursing Care Center , Sentinel Event , Sentinel Event Alert , Safe Health IT

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
Topics Library

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

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Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and...

Related Items: Behavioral Health Care , Sentinel Event , Sentinel Event Alert

07/09/2008
Topics Library

Sentinel Event Alert, Issue 39: Preventing pediatric medication errors

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Errors associated with medications are believed to be the most common type of medical error and are a significant cause of preventable adverse events.

Related Items: Medication Errors , Sentinel Event , Sentinel Event Alert

04/11/2008
Topics Library

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

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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 Items: Sentinel Event , Sentinel Event Alert

02/14/2008
Topics Library

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

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Health care facilities are highly dependent on reliable sources of electrical power.

Related Items: Sentinel Event , Sentinel Event Alert

09/06/2006
Topics Library

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

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This Sentinel Event Alert has been retired. March 2016. It has been replaced with Sentinel Event Alert, Issue 53: Managing risk during transition to new ISO tubing connector standards.

Related Items: Sentinel Event , Sentinel Event Alert

04/03/2006
Topics Library

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

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Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking.

Related Items: Medication Errors , Sentinel Event , Sentinel Event Alert

01/25/2006
Topics Library

Sentinel Event Alert, Issue 34: Preventing vincristine administration errors

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Despite repeated warnings over the years and extensive labeling requirements and standards, tragic errors related to the inadvertent administration of vincristine intrathecally...

Related Items: Sentinel Event , Sentinel Event Alert

07/14/2005
Topics Library

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

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This Sentinel Event Alert has been retired. Current information is provided in Sentinel Event Alert #49: Safe use of opioids in hospitals.

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

12/20/2004
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