Sentinel Event Alert Newsletters

Sentinel Event Alert newsletters identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. Accredited organizations should consider information in a Sentinel Event Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the alert or reasonable alternatives.

• Sentinel Event Alert 65: Diagnostic overshadowing among groups experiencing health disparities
• Sentinel Event Alert 64: Addressing health care disparities by improving quality and safety
• Sentinel Event Alert 63: Optimizing smart infusion pump safety with DERS
• Sentinel Event Alert 62: Special Edition - Voices from the pandemic: Health care workers in the midst of crisis
• Sentinel Event Alert 61: Managing the risks of direct oral anticoagulants
• Sentinel Event Alert 60: Developing a reporting culture: Learning from close calls and hazardous conditions
• Sentinel Event Alert 59: Physical and verbal violence against health care workers
• Sentinel Event Alert 58: Inadequate hand-off communication
• Sentinel Event Alert 57: The essential role of leadership in developing a safety culture
• Sentinel Event Alert 56: Detecting and treating suicide ideation in all settings
• Sentinel Event Alert 55: Preventing falls and fall-related injuries in health care facilities
• Sentinel Event Alert 54: Safe use of health information technology
• Sentinel Event Alert 53: Managing risk during transition to new ISO tubing connector standards
• Sentinel Event Alert 52: Preventing infection from the misuse of vials
• Sentinel Event Alert 51: Preventing unintended retained foreign objects
• Sentinel Event Alert 50: Medical device alarm safety in hospitals
• Sentinel Event Alert 49: Safe use of opioids in hospitals
• Sentinel Event Alert 48: Health care worker fatigue and patient safety
• Sentinel Event Alert 47: Radiation risks of diagnostic imaging and fluoroscopy
• Sentinel Event Alert 46: A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department
• Sentinel Event Alert 45: Preventing violence in the health care setting
• Sentinel Event Alert 44: Preventing Maternal Death
• Sentinel Event Alert 43: Leadership committed to safety
• Sentinel Event Alert 42: Safely implementing health information and converging technologies
• Sentinel Event Alert 41: Preventing errors relating to commonly used anticoagulants
• Sentinel Event Alert 40: Behaviors that undermine a culture of safety
• Sentinel Event Alert 39: Preventing pediatric medication errors
• Sentinel Event Alert 38: Preventing accidents and injuries in the MRI suite
• Sentinel Event Alert 37: Preventing adverse events caused by emergency electrical power system failures
• Sentinel Event Alert 36: Tubing misconnections a persistent and potentially deadly occurrence
• Sentinel Event Alert 35: Using medication reconciliation to prevent errors
• Sentinel Event Alert 34: Preventing vincristine administration errors
• Sentinel Event Alert 33: Patient controlled analgesia by proxy
• Sentinel Event Alert 32: Preventing, and managing the impact of, anesthesia awareness
• Sentinel Event Alert 31: Revised guidance to help prevent kernicterus
• Sentinel Event Alert 30: Preventing infant death and injury during delivery
• Sentinel Event Alert 29: Preventing surgical fires
• Sentinel Event Alert 28: Infection control related sentinel events
• Sentinel Event Alert 27: Bed rail-related entrapment deaths
• Sentinel Event Alert 26: Delays in treatment
• Sentinel Event Alert 25: Preventing ventilator-related deaths and injuries
• Sentinel Event Alert 24: A follow-up review of wrong site surgery
• Sentinel Event Alert 23: Medication errors related to potentially dangerous abbreviations
• Sentinel Event Alert 22: Preventing needlestick and sharps injuries
• Sentinel Event Alert 21: Medical gas mix-ups
• Sentinel Event Alert 20: Exposure to Creutzfeldt-Jakob Disease
• Sentinel Event Alert 19: Look-alike, sound-alike drug names
• Sentinel Event Alert 18: Kernicterus threatens healthy newborns
• Sentinel Event Alert 17: Lessons Learned: Fires in the Home Care Setting
• Sentinel Event Alert 16: Mix-up Leads to a Medication Error
• Sentinel Event Alert 15: Infusion Pumps: Preventing Future Adverse Events
• Sentinel Event Alert 14: Fatal Falls: Lessons for the Future
• Sentinel Event Alert 13: Making an Impact on Health Care
• Sentinel Event Alert 12: Operative and Post-Operative Complications: Lessons for the Future
• Sentinel Event Alert 11: High-Alert Medications and Patient Safety
• Sentinel Event Alert 10: Blood Transfusion Errors: Preventing Future Occurrences
• Sentinel Event Alert 9: Infant Abductions: Preventing Future Occurrences
• Sentinel Event Alert 8: Preventing Restraint Deaths
• Sentinel Event Alert 7: Inpatient Suicides: Recommendations for Prevention
• Sentinel Event Alert 6: Lessons Learned: Wrong Site Surgery
• Sentinel Event Alert 5: Board Votes To Increase Time Frame For Submitting Root Cause Analysis
• Sentinel Event Alert 4: Examples Of Voluntarily Reportable Sentinel Events
• Sentinel Event Alert 3: Board of Commissioners Affirms Support For Sentinel Event Policy
• Sentinel Event Alert 2: Board To Review Modifications To Sentinel Event Procedures
• Sentinel Event Alert 1: New Publication