Sentinel Event Alert, Issue 18: Kernicterus threatens healthy newborns
This Sentinel Event Alert has been retired. August 2015.
View ArticleSentinel Event Alert, Issue 19: Look-alike, sound-alike drug names
This Sentinel Event Alert has been retired. August 2015.
View ArticleSentinel Event Alert, Issue 20: Exposure to Creutzfeldt-Jakob Disease
This Sentinel Event Alert has been retired. August 2015.
View ArticleSentinel Event Alert, Issue 21: Medical gas mix-ups
This Sentinel Event Alert has been retired. More current, focused information is provided in Sentinel Event Alert, Issue 53: Managing risk during transition to new ISO tubing connector standards.
View ArticleSentinel Event Alert, Issue 22: Preventing needlestick and sharps injuries
This Sentinel Event Alert has been retired. Guidance to prevent needlestick and sharps injuries is provided by the Centers for Disease Control and Prevention (CDC) and the Occupational Safety &...
View ArticleSentinel Event Alert, Issue 23: Medication errors related to potentially...
One of the major causes of medication errors is the ongoing use of potentially dangerous abbreviations and dose expressions.
View ArticleSentinel Event Alert, Issue 24: A follow-up review of wrong site surgery
This Sentinel Event Alert has been retired. November 2014.
View ArticleSentinel Event Alert, Issue 25: Preventing ventilator-related deaths and...
This Sentinel Event Alert has been retired. March 2016. Current, focused information is provided in Sentinel Event Alert, Issue 53: Managing risk during transition to new ISO tubing connector...
View ArticleSentinel Event Alert, Issue 26: Delays in treatment
This Sentinel Event Alert has been retired. More current, focused information is provided in Quick Safety, Issue #9: Preventing delays in treatment.
View ArticleSentinel Event Alert, Issue 27: Bed rail-related entrapment deaths
This Sentinel Event Alert has been retired. March 2016
View ArticleSentinel 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...
View ArticleSentinel 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...
View ArticleSentinel Event Alert, Issue 30: Preventing infant death and injury during...
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...
View ArticleSentinel Event Alert, Issue 31: Revised guidance to help prevent kernicterus
This Sentinel Event Alert has been retired. August 2015.
View ArticleSentinel Event Alert, Issue 32: Preventing, and managing the impact of,...
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...
View ArticleSentinel 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.
View ArticleSentinel 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...
View ArticleSentinel Event Alert, Issue 35: Using medication reconciliation to prevent...
Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking.
View ArticleSentinel Event Alert, Issue 36: Tubing misconnections—a persistent and...
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.
View ArticleSentinel Event Alert, Issue 37: Preventing adverse events caused by emergency...
Health care facilities are highly dependent on reliable sources of electrical power.
View ArticleSentinel Event Alert, Issue 38: Preventing accidents and injuries in the MRI...
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.
View ArticleSentinel 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.
View ArticleSentinel 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...
View ArticleSentinel Event Alert, Issue 41: Preventing errors relating to commonly used...
Reports of accidental deaths and overdosing due to the improper use of anticoagulant drugs have received significant public attention.
View ArticleSentinel Event Alert, Issue 42: Safely implementing health information and...
As health information technology (HIT) and “converging technologies”—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations.
View ArticleSentinel 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...
View ArticleSentinel 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
View ArticleSentinel 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.
View ArticleSentinel Event Alert, Issue 46: A follow-up report on preventing suicide:...
This Sentinel Event Alert has been retired. It has been replaced with Sentinel Event Alert #56: Detecting and treating suicide ideation in all settings.
View ArticleSentinel 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...
View ArticleSentinel 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...
View ArticleSentinel 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...
View ArticleSentinel 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...
View ArticleAddendum to Sentinel Event Alert Issue 20: Exposure to Creutzfeldt-Jakob...
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.
View ArticlePreventing suicide among ED patients – a realizable goal
An immediately recognizable unnecessary death in an ED is a suicide that was initiated in the ED itself. These suicides need not occur if suicidal patients are recognized, appropriate immediate...
View ArticleSentinel Event Alert Issue 51: Preventing unintended retained foreign objects
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...
View ArticleSentinel Event Alert Issue 52: Preventing infection from the misuse of vials
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.
View ArticleSentinel Event Alert 53: Managing risk during transition to new ISO tubing...
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)...
View ArticleSentinel Event Alert 54: Safe use of health information technology
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...
View ArticleSentinel Event Alert 55: Preventing falls and fall-related injuries in health...
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.
View ArticleSentinel Event Alert 57: The essential role of leadership in developing a...
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...
View ArticleSentinel Event Alert 58: Inadequate hand-off communication
Health care professionals typically take great pride and exert painstaking effort to meet patient needs and provide the best possible care.
View ArticleDo You Really Understand Your Hand-off Communication Processes?
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...
View ArticleSentinel Event Alert 59: Physical and verbal violence against health care...
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...
View ArticleWorkplace Violence Prevention: Implementing Strategies for Safer Healthcare...
Watch this webinar replay to learn from work done by OSHA and The Joint Commission, as well as Judith Arnetz, PhD, MPH, PT, of the Department of Family Medicine at Michigan State University.
View ArticleSentinel Event Alert 60: Developing a reporting culture: Learning from close...
Identifying and reporting unsafe conditions before they can prevent harm, trusting that other staff and leadership will act on the report, and taking personal responsibility for one’s actions are...
View ArticleSentinel Event Alert 56: Detecting and treating suicide ideation in all...
This Sentinel Event Alert has been retired as of February 2019.
View ArticleDeveloping a Reporting Culture
In December 2018, The Joint Commission released Sentinel Event Alert 60: Developing a reporting culture: Learning from close calls and hazardous conditions. Watch the replay of the follow-up webinar to...
View ArticleSentinel Event Alert 61: Managing the risks of direct oral anticoagulants
While DOACs offer ease of use to patients, stopping bleeding events in patients on DOACs is more complicated, requiring different strategies than those for patients on warfarin (Coumadin®) and heparin.
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