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Ambulatory Health Care, Hospitals, Critical Access Hospitals, Behavioral Health Care, Laboratory , Nursing Care Center, Office-Based Surgery, Home Care, Disease-Specific Care, Bureau of Primary Health Care, Palliative Care, Integrated Care , Perinatal Care, Patient Blood Management Certification

Sentinel Event Alert 59: Physical and verbal violence against health care workers

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The focus of Sentinel Event Alert #59 is to help your organization recognize and acknowledge workplace violence directed against health care workers from patients and visitors, better prepare staff to handle violence, and more effectively address the aftermath.

Related Topics: Sentinel Event Alert

04/16/2018

Do You Really Understand Your Hand-off Communication Processes?

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In September 2017, The Joint Commission released Sentinel Event Alert 58: Inadequate hand-off communication. As a webinar complement to this publication, a panel of Joint Commission patient safety professionals dove deep into a case study to examine what really causes hand-off communication errors.

Related Topics: Webinar, Sentinel Event Alert

10/27/2017

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Behavioral Health Care, Laboratory , Nursing Care Center, Office-Based Surgery, Home Care, Disease-Specific Care, Health Care Staffing Services, Palliative Care, Primary Care Medical Home, Integrated Care , Perinatal Care, Patient Blood Management Certification, Comprehensive Cardiac Center, Medication Compounding Certification

Sentinel Event Alert 58: Inadequate hand-off communication

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Health care professionals typically take great pride and exert painstaking effort to meet patient needs and provide the best possible care.

Related Topics: Sentinel Event, Sentinel Event Alert

09/11/2017

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Behavioral Health Care, Laboratory , Nursing Care Center, Office-Based Surgery, Home Care, Advanced Disease-Specific Care Certification , Disease-Specific Care, Health Care Staffing Services, Bureau of Primary Health Care, Palliative Care, Primary Care Medical Home, Integrated Care , Perinatal Care, Patient Blood Management Certification

Sentinel Event Alert 57: The essential role of leadership in developing a safety culture

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In any health care organization, leadership’s first priority is to be accountable for effective care while protecting the safety of patients, employees, and visitors. Competent and thoughtful leaders contribute to improvements in safety and organizational culture.

Related Topics: Sentinel Event Alert, Sentinel Event, Nursing Care Center, Laboratory Accreditation Program, Hospital, Home Care, Critical Access Hospital, Disease-Specific Care, Health Care Staffing, Ambulatory Health Care, Behavioral Health Care, Patient Blood Management Certification, Integrated Care Certification, Webinar, Suicide, Palliative Care

03/01/2017

Ambulatory Health Care, Hospitals, Critical Access Hospitals, Behavioral Health Care, Laboratory , Nursing Care Center, Office-Based Surgery, Home Care, Advanced Disease-Specific Care Certification , Disease-Specific Care, Health Care Staffing Services, Bureau of Primary Health Care, Palliative Care, Primary Care Medical Home, Integrated Care , Perinatal Care, Patient Blood Management Certification

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 Topics: Sentinel Event Alert, Sentinel Event, Nursing Care Center, Laboratory Accreditation Program, Behavioral Health Care, Critical Access Hospital, Ambulatory Health Care, Home Care, Hospital, Health Care Staffing, Disease-Specific Care, Integrated Care Certification, Palliative Care, Suicide, Webinar, Patient Blood Management Certification

02/24/2016

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

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 Topics: Sentinel Event Alert, Falls

09/28/2015

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

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 Topics: Safe Health IT, Sentinel Event Alert

03/31/2015

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

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

08/20/2014

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

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 Topics: Sentinel Event, Sentinel Event Alert, Sentinel Event Infection, Infection Prevention and HAIs

06/16/2014

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

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 Topics: Sentinel Event, Sentinel Event Alert, Office-Based Surgery, Ambulatory Health Care, Hospital, Critical Access Hospital, Webinar

10/17/2013

Hospitals, Critical Access Hospitals

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 Topics: Sentinel Event Infection, Infection Prevention and HAIs, Sentinel Event Alert

09/18/2013

Hospitals, Critical Access Hospitals

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 Topics: Hospital, Critical Access Hospital, Sentinel Event Alert, Sentinel Event, Infographic, Webinar

04/08/2013

Hospitals, Critical Access Hospitals

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 Topics: Sentinel Event, Sentinel Event Alert, Pain Management, Newsletter, Opioids

08/08/2012

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

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 Topics: Sentinel Event, Sentinel Event Alert, Newsletter, Patient Safety, Fatigue

12/14/2011

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

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

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(Addendum May 2017) 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.

Related Topics: Ambulatory Health Care, Critical Access Hospital, Hospital, Sentinel Event Alert, Sentinel Event, Radiation Overdose

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

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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 Topics: Sentinel Event, Sentinel Event Alert

11/17/2010

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

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

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(Addendum, February 2017) 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 Topics: Ambulatory Health Care, Behavioral Health Care, Critical Access Hospital, Hospital, Sentinel Event Alert, Sentinel Event

06/03/2010

Hospitals, Critical Access Hospitals

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. NOTE: This Sentinel Event Alert was retired in September 2016.

Related Topics: Sentinel Event, Sentinel Event Alert

01/26/2010

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

Sentinel Event Alert, Issue 43: Leadership committed to safety

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This Sentinel Event Alert has been retired.

Related Topics: Hospital, Laboratory Accreditation Program, Nursing Care Center, Sentinel Event, Sentinel Event Alert, Home Care, Critical Access Hospital, Behavioral Health Care, Ambulatory Health Care

08/27/2009

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

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 Topics: Sentinel Event, Sentinel Event Alert, Laboratory Accreditation Program, Nursing Care Center, Behavioral Health Care, Critical Access Hospital, Ambulatory Health Care, Hospital, Home Care, Safe Health IT

12/11/2008

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

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 Topics: Sentinel Event, Sentinel Event Alert, Nursing Care Center, Critical Access Hospital, Hospital, Home Care, Ambulatory Health Care

09/24/2008

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

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 Topics: Behavioral Health Care, Sentinel Event Alert, Sentinel Event

07/09/2008

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

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 Topics: Medication Errors, Sentinel Event Alert, Sentinel Event

04/11/2008

Ambulatory Health Care, Hospitals, Critical Access Hospitals

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. NOTE: This Sentinel Event Alert was retired in August 2016.

Related Topics: Sentinel Event Alert, Sentinel Event

02/14/2008

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

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. NOTE: This Sentinel Event Alert was retired in August 2016.

Related Topics: Sentinel Event, Sentinel Event Alert

09/06/2006

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