Sentinel 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...
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