Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.
Accredited organizations should consider information in an Alert when designing or redesigning relevant processes and consider implementing relevant suggestions or reasonable alternatives.
Please route this issue to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to the Joint Commission.
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