Sentinel events. In memory of Ben—a case study.
Haas D. Jt Comm Perspect. March/April 1997;17:12-15.
Written from the perspective of a risk manager, the author tells the story of a medication administration error that led to the death of a 7-year-old boy. Without focusing on the details of the error, the author describes the investigative process that uncovered it, the careful attention paid to communication with the bereaved parents, and the administrative steps taken subsequently to reduce the risk of similar events. The author describes a collaborative, mutually supportive, systems-oriented approach to safety in place at her institution, crediting this approach with a favorable resolution to a tragic incident. This story is also discussed in the video
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
Conway JB, Weingart SN. AHRQ WebM&M [serial online]. May 2005.
The Joint Commission.
Patient controlled analgesia by proxy.
The Joint Commission. Sentinel Event Alert. December 20, 2004;(33):1-2.
Sentinel Event Alert.
Oakbrook Terrace, IL: The Joint Commission.
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