Sentinel 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 ArticleNew Sentinel Event Alert Focuses on Preventing Patient Falls
Preventing patient falls and fall-related injuries is the focus of a new Sentinel Event Alert.
View ArticleSentinel Event Alert 56: Detecting and treating suicide ideation in all...
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...
View ArticleNew Sentinel Event Alert on Preventing Suicide in Health Care Settings
The Joint Commission today issued Sentinel Event Alert: Issue 56 on preventing suicide in health care settings.
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