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Sentinel Event Alert. 2018;59:1-9 (revised June 18, 2021).
The Joint Commission issues sentinel event alerts to raise awareness regarding risks in the health care setting. This alert highlights physical and verbal violence as a major problem in the workplace, particularly in areas such as the emergency department and inpatient psychiatric units. Other factors associated with violence in health care settings include stressful conditions, understaffing, and lack of organizational policies for recognizing and deescalating hostile behaviors. The alert suggests numerous strategies health care organizations can take to mitigate workplace violence, such as establishing systems across the organization that enable reporting of workplace violence and developing quality improvement initiatives to reduce such incidents. A past PSNet perspective explored how a team at Beth Israel Deaconess Medical Center developed a process to improve workplace safety.
Trent M, Dooley DG, Dougé J, et al. Pediatrics. 2019;144:e20191765.
Children and adolescents are particularly vulnerable to systemic weaknesses in health care. This guidance examines the impact of racism and implicit biases on pediatric patients. The policy summarizes the evidence on institutionalized racism and health to motivate the adoption of strategies to reduce that impact at the system and organizational level.
Rosengart TK, Doherty G, Higgins R, et al. JAMA Surg. 2019;154:647-653.
Potential deterioration of older surgeons' technical performance is a patient safety concern. This guidance developed from a Society of Surgical Chairs panel discussion puts forth several steps to manage the transition of aging surgeons. Recommendations include mandatory cognitive and psychomotor testing for surgeons age 65 and older, respectful consideration of the financial and emotional concerns of aging surgeons, and lifelong mentoring around the transition from clinical to nonclinical roles. The authors anticipate that such initiatives will prompt thoughtful support for aging surgeons that ensures patient safety. In an accompanying editorial, an older physician supports mandatory testing and suggests individual-level steps to address aging as a surgeon, including healthy lifestyle and financial habits.
Lehmann LS, Sulmasy LS, Desai S, et al. Ann Intern Med. 2018;168:506-508.
In medical training, learners glean messages from the offhand comments, behaviors, and attitudes of their superiors, a phenomenon known as the hidden curriculum. Experts have described how the hidden curriculum often runs counter to a culture of safety and standards of equitable treatment. In this position statement, the American College of Physicians recommends that educators recognize and optimize the hidden curriculum in physician training through promoting an expectation of professionalism as a core value, empowering learners to raise concerns about safety, and modeling empathy, reflection, and discussion of positive and negative experiences in the training environment.
Moss M, Good VS, Gozal D, et al. Crit Care Med. 2016;44:1414-21.
Burnout in health care is a recognized issue that can diminish patient safety. This statement raises awareness of burnout in critical care clinicians, discusses organizational and individual factors associated with the problem, and offers strategies to prevent and address burnout. Recommended solutions include career counseling for new critical care clinicians and training for intensive care unit leaders to help them recognize problems that contribute to burnout and design interventions.
Sentinel event alert. 2016:1-7.
The Joint Commission publishes sentinel event alerts to emphasize pressing safety issues, determine root causes, and provide guidelines for organizations on how to address them. In light of receiving 1089 reports of suicide between 2010 and 2014, this new alert focuses on preventing suicide in health care settings. Many of the suicide cases investigated across health care settings had involved inadequate assessments or lack of identification of suicidal ideation. The alert suggests that all health care providers should screen for suicidal ideation and review patients for suicide risk factors. A previous WebM&M commentary discusses a suicide attempt on an inpatient medical unit. Note: This alert has been retired effective February 2019. Please refer to the information link below for further details.

Fla Ct App, 1st Dist. October 28, 2015.

The Patient Safety and Quality Improvement Act (PSQIA) provides federal protection of adverse event reports voluntarily submitted to patient safety organizations in an effort to enable disclosure and subsequent discussion of error to enhance learning from errors. This case tested the ability of the federal law to block access to such reports when conflicting with state laws in Florida. The court found that PSQIA provided appropriate protection for the records.
London, UK: General Medical Council and the Nursing and Midwifery Council; June 29, 2015.
Open and honest discussion with patients after an error or near miss is key to effective disclosure. This guidance provides recommendations for physicians, nurses, and midwives regarding disclosure practices in the United Kingdom. A set of case studies accompanies the report, which illustrate the professional duty of candor in various practical situations.
Sentinel Event Alert. 2010;46:1-4.
Suicide among hospitalized patients remains an under-recognized never event, as it has ranked among the most common sentinel events reported to The Joint Commission over the past decade. While specialized psychiatric units are designed and staffed to minimize suicide risk, emergency departments and general medical wards are not, and prior research has shown that a significant proportion of inpatient suicide attempts occur in these settings. This Sentinel Event Alert reviews risk factors for inpatient suicide and delineates prevention strategies hospitals can use to minimize risk. A case of an inpatient suicide attempt on a general medical ward is discussed in this AHRQ WebM&M commentary. Note: This alert has been retired effective February 2016. Please refer to the information link below for further details.