Other specialty areas include sentinel event
analysis, management of hospital readmissions, regulatory and HIPAA compliance, ICD-10 education, revenue cycle management, and other professional services that support and enhance the strategic initiatives of healthcare organizations of any type, including acute and long-term care providers.
Technology related safety issues such as ventilators and tubing misconnections have been previously addressed through Sentinel Event
As discussed in the National Institute of Justice (NIJ) Special Report Mending Justice: Sentinel Event
Reviews, published in September 2014, some believe the criminal justice system lacks a feature that medicine, aviation and other high-risk enterprises see as critical: a way to account for tragic outcomes and using those lessons to reduce risk of recurrence.
The risk to the patient is that they get the wrong dose--too much or too little or wrong medication--which will have a significant impact on the patient concerned and result in a sentinel event
In June 2008, the Joint Commission issued a Sentinel Event
Alert describing "behaviors that undermine a culture of safety.
The Joint Commission's Sentinel Event
database has reports of 98 alarm-related events between January 2009 and June 2012, with 80 resulting in death, 13 in permanent loss of function and five in unexpected additional care or extended stay.
In April 2006, The Joint Commission issued a Sentinel Event
Alert titled "Tubing misconnections--a persistent and potentially deadly occurrence" that offered strategies for healthcare organizations to reduce risk and called upon manufacturers to redesign products to prevent misconnections.
The Joint Commission: Sentinel Event
Root Cause and Trend Data, www.
1), (2), (3), (4), (5) While it is acknowledged that many factors contribute to fatigue, including but not limited to insufficient staffing and excessive workloads, the purpose of this Sentinel Event
Alert is to address the effects and risks of an extended work day and of cumulative days of extended work hours.
Communication errors are the sentinel event
in the vast majority of perinatal adverse events," he said.
The Joint Commission issued Sentinel Event
Alert #38 which recognizes the use of Ferromagnetic Detectors to assist in the screening process.
In November 2010, the Joint Commission released a Sentinel Event
Alert, noting that nearly 25 percent of hospital suicides were occurring in areas outside of hospitals1 inpatient psychiatric units.