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The Joint Commission.

Since 1998, The Joint Commission has issued sentinel event alerts in response to unexpected incidents involving death or serious physical or psychological injury (or risk thereof). These events are identified as sentinel due to the gravity of the injury and the need for immediate investigation and response. The goal is often to determine the root causes involved and provide recommendations for future prevention. The Sentinel Event Alert Web site includes a complete library of previous sentinel event alerts, along with related statistics, podcasts, forms, tools, policy and procedures, and a frequently asked questions section reviewing selected recent topics.

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Related Resources
PRESS RELEASE/ANNOUNCEMENT
Patient controlled analgesia by proxy.
The Joint Commission. Sentinel Event Alert. December 20, 2004;(33):1-2.
NEWSLETTER/JOURNAL
Sentinel Event Alert.
Oakbrook Terrace, IL: The Joint Commission.
STUDY
Sentinel events. In memory of Ben—a case study.
Haas D. Jt Comm Perspect. March/April 1997;17:12-15.
BOOK/REPORT
4th Ed. Patient Safety Essentials for Health Care.
Oakbrook Terrace, IL; Joint Commission on Accreditation of Healthcare Organizations; 2006. ISBN: 0866889892.
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