JCAHO SENTINEL EVENT INFORMATION

Published for Joint Commission accredited organizations
and interested health care professionals,
Sentinel Event Alert identifies the most frequently occurring sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.
      During the on-site survey of accredited organizations, JCAHO surveyors assess the organization's familiarity with and use of Sentinel Event Alert information. Organizations are expected to:
    (1) review each Sentinel Event Alert,
    (2) consider the suggestions, as appropriate to the organization's services, and
    (3) implement the suggestions, or reasonable alternatives, or provide a reasonable explanation for not implementing relevant changes.
      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 on Accreditation of Healthcare Organizations.
JCAHO articles regarding Sentinel Events Applies
to BHC?
Leadership
Review
Action
Required?
1 27-Jun-01 Sentinel Event Statistics yes SERC - PIC no
2 Glossary yes SERC - PIC no
3 Reporting of Medical/Health Care Errors yes SERC - PIC yes
Sentinel Event Alert Policies & Procedures Applies
to BHC?
Leadership
Review
Action
Required?
 Issue
Date
Topic
4 20-Mar-98 Board To Review Modifications To Sentinel Event Procedures yes SERC - PIC  
5 01-May-98 Board Approves Changes to Sentinel Event Policy and Procedures yes SERC - PIC  
6 11-May-98 Accreditation Committee Approves Examples Of Voluntarily Reportable Sentinel Events yes SERC - PIC  
7 24-Jul-98 Board Approves Changes to Sentinel Event Policy And Procedures yes SERC - PIC  
Sentinel Event Alert Issues Applies
to BHC?
Leadership
Review
Action
Required?
 Issue
Date
Topic
8 27-Feb-98 Medication Error Prevention - Potassium Chloride      
9 28-Aug-98 Lessons Learned: Wrong Site Surgery      
10 06-Nov-98 Inpatient Suicides: Recommendations for Prevention      
11 18-Nov-98 Preventing Restraint Deaths      
12 30-Aug-99 Blood Transfusion Errors: Preventing Future Occurrences      
13 19-Nov-99 High-Alert Medications and Patient Safety      
14 04-Feb-00 Operative and Post-Operative Complications: Lessons for the Future      
15 21-Apr-00 Making an Impact on Health Care      
16 12-Jul-00 Fatal Falls: Lessons for the Future      
17 30-Nov-00 Infusion Pumps:  Preventing Future Adverse Events      
18 27-Feb-01 Mix-up Leads to a Medication Error      
19 20-Mar-01 Lessons Learned: Fires in the Home Care Setting      
20 01-Apr-01 Kernicterus Threatens Healthy Newborns      
21 01-May-01 Look-alike, Sound-alike Drug Names      
22 01-Jun-01 Exposure to Creutzfeldt-Jakob Disease