Sentinel Event Alert

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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Index of Issues


Issue 42 - December 11, 2008: Safely implementing health information and converging technologies
Issue 41 – September 24, 2008: Preventing errors relating to commonly used anticoagulants
Issue 40 - July 9, 2008: Behaviors that undermine a culture of safety
Issue 39 - April 11, 2008: Preventing pediatric medication errors
Issue 38 - February 14, 2008: Preventing accidents and injuries in the MRI suite
Issue 37 - September 6, 2006: Preventing adverse events caused by emergency electrical power system failures
Issue 36 - April 3, 2006: Tubing misconnections—a persistent and potentially deadly occurrence
Issue 35 - January 25, 2006: Using medication reconciliation to prevent errors
Issue 34 - July 14, 2005: Preventing vincristine administration errors
Issue 33 - December 20, 2004: Patient controlled analgesia by proxy
Issue 32 - October 6, 2004: Preventing, and managing the impact of, anesthesia awareness
Issue 31 - August 31, 2004: Revised guidance to help prevent kernicterus
Issue 30 - July 21, 2004: Preventing infant death and injury during delivery
Issue 29 - June 24, 2003: Preventing surgical fires
Issue 28 - January 22, 2003: Infection control related sentinel events
Issue 27 - September 6, 2002: Bed rail-related entrapment deaths
Issue 26 - June 17, 2002: Delays in treatment
Issue 25 - February 26, 2002: Preventing ventilator-related deaths and injuries
Issue 24 - December 5, 2001: A follow-up review of wrong site surgery
Issue 23 - September 1, 2001: Medication errors related to potentially dangerous abbreviations
Issue 22 - August 1, 2001: Preventing needlestick and sharps injuries
Issue 21 - July 1, 2001: Medical gas mix-ups
Issue 20 - June 1, 2001: Exposure to Creutzfeldt-Jakob Disease
Issue 19 May 1, 2001: Look-alike, sound-alike drug names
Issue 18 - April 1, 2001: Kernicterus threatens healthy newborns
Issue 17 - March 1, 2001: Lessons Learned: Fires in the Home Care Setting
Issue 16 - February 27, 2001: Mix-up Leads to a Medication Error
Issue 15 - November 30, 2000: Infusion Pumps: Preventing Future Adverse Events
Issue 14 - July 12, 2000: Fatal Falls: Lessons for the Future
Issue 13 - April 21, 2000: Making an Impact on Health Care
Issue 12 - February 4, 2000: Operative and Post-Operative Complications: Lessons for the Future
Issue 11 - November 19, 1999: High-Alert Medications and Patient Safety
Issue 10 - August 30, 1999: Blood Transfusion Errors: Preventing Future Occurrences
Issue 9 - April 9, 1999: Infant Abductions: Preventing Future Occurrences
Issue 8 - November 18, 1998: Preventing Restraint Deaths
Issue 7 - November 6, 1998: Inpatient Suicides: Recommendations for Prevention
Issue 6 - August 28, 1998: Lessons Learned: Wrong Site Surgery
Issue 5 - July 24, 1998: Board Votes To Increase Time Frame For Submitting Root Cause Analysis
Issue 4 - May 11, 1998: Examples Of Voluntarily Reportable Sentinel Events
Issue 3 - May 1, 1998: Board of Commissioners Affirms Support For Sentinel Event Policy
Issue 2 - March 20, 1998: Board To Review Modifications To Sentinel Event Procedures
Issue 1 - February 28, 1998: New Publication