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Sentinel Event Alert 16: Mix-up Leads to a Medication Error

This Sentinel Event Alert has been retired as of August 2015. To help organizations proactively address patient safety events, The Joint Commission provides detailed information online, including its Sentinel Event policy and the Patient Safety Systems chapter of the accreditation manual.

Note: Retired Alerts are not available for any purpose, including for educational, research or legal purposes. Questions should be directed to The Joint Commission’s Legal Department at 630-792-5671.