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Sentinel event alert. 2017;58:1-6.
The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety issues and provide guidelines for organizations on how to address them. This alert highlights potential safety hazards at the time of handoffs, defined as "a transfer and acceptance of patient care responsibility achieved through effective communication." Handoffs can occur within or across settings of care (e.g., between two clinicians in the same hospital or between a hospital and a long-term care facility). To ensure high-quality handoffs, the alert recommends that health care organizations take several actions, including providing handoff training to clinicians, engaging leadership in prioritizing handoffs as an essential part of a culture of safety, and using continuous improvement methodology to monitor and enhance handoffs. High-quality research has defined effective communication techniques for preventing handoff errors (such as the I-PASS mnemonic), and the alert specifically recommends use of these tools. A past WebM&M commentary discussed a handoff error that nearly resulted in serious patient harm.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee. Pediatrics. 2016;138:e20162680.

Improvement efforts have focused on care transitions, which are known to be vulnerable to communication failures. This guideline provides recommendations for ensuring handoffs are performed in pediatric emergency care and suggests adherence to standard communication methods, coupled with effective training on the use of those tools, can improve the safety of transitions.
Jewell JA. Pediatrics. 2016;138:e20162681.
Handoffs at shift changes are vulnerable to communication errors, which can result in patient harm. This guideline describes how to improve handoffs, including by standardizing content, dedicating certain locations and time periods to reduce interruptions, and using technological resources to augment accuracy of handoff information. A past PSNet perspective discussed safe inpatient handovers.
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014).
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Sentinel Event Alert. 2010;44:1-4.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will be distributed by a new initiative. Please refer to the information link below for further details.
Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.
Sentinel Event Alert. 2008;41:1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission. Note: This alert has been retired effective October 2019. Please refer to the full-text link below for further information.
Sentinel Event Alert. 2006;35:1-4.
This alert emphasizes the importance of reconciling medications and supports implementation of this Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goal. Note: This alert has been retired effective August 2016. Please refer to the information link below for further details.

Sentinel Event Alert. December 14, 2011;(48):1-4. (addendum May 14, 2018).

The Joint Commission issues sentinel event alerts to emphasize pressing safety issues and provide guidelines for organizations on how to address them. The link between health care worker fatigue and patient safety has been established in seminal studies, which have demonstrated that the risk of error increases when nurses work more than 12 hours per shift and when resident physicians work more than 16 consecutive hours. In response to these data, the Accreditation Council for Graduate Medical Education (ACGME) further restricted resident duty hours in 2011. This alert calls on hospitals to design work schedules to minimize fatigue risks, monitor the safety of handoffs, and provide education for clinicians on fatigue management strategies. The combination of the ACGME regulations and this sentinel event alert provides a powerful incentive for teaching hospitals and residency programs to harmonize efforts around minimizing the risk of fatigue-related complications.