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Sentinel Event Alert. 2010:1-3.
Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk and to promote rapid adoption of risk reduction strategies. This newly released alert focuses on violence in the health care setting, noting increasing rates of violent crimes such as assault, rape, and homicide, which are consistently among the top 10 types of sentinel events reported. Controlling access is viewed as a key protection strategy, and the alert also outlines techniques for identifying violent individuals and for training staff in violence management. The alert summarizes a series of suggested actions that will allow organizations to safeguard against these events. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys.

Sentinel Event Alert. Feb 2, 2021;(62):1-7. 

Safe patient care is reliant on a healthy healthcare workforce. This alert emphasizes organizational conditions and supporting the wellbeing of clinicians under the stress of providing care during the COVID-19 pandemic. 
Accreditation Council for Graduate Medical Education; ACGME.
Implementation of resident duty hours, meant to address fatigue in health care, has long been a subject of patient safety discussions. This website provides a summary of proposed changes to the current ACGME residency Common Program Requirements that shape working hours, offers rationale for the revisions.
Silver Spring, MD: American Nurses Association; September 2014.
Fatigue is known to contribute to mistakes and omissions in nursing care. This position statement outlines the shared responsibility of nurses and health care organizations to limit the conditions that contribute to nurse fatigue such as shift work, personal habits, and mandatory overtime.

Neville K, Galinkin JL, Green TP, et al; Committee on Drugs of the American Academy of Pediatrics. Pediatrics. 2015;135(4):784-787.

Accidental overdoses can occur when oral medications are given to children using teaspoons as measurement devices. This policy statement recommends use of milliliter-based dosing devices to enable metric-based administration of liquid medications to pediatric patients.

Hearings before the Subcommittee on Health of the Committee on Energy and Commerce Committee, 112th Cong, 1st Sess (September 23, 2011).

This hearing focused on the problem of medication shortages and its impact on patients, hospitals, and providers.
Sentinel event alert. 2008:1-4.
As health information technologies such as computerized provider order entry are implemented more widely, awareness of the unintended consequences of these technologies has increased. Both electronic medical records and computerized order entry have been associated with significant problems relating to altered workflow and communication patterns. This sentinel event alert from the Joint Commission reviews the types of adverse events associated with information technology and gives detailed recommendations for how institutions should integrate new technologies. The alert stresses the importance of involving frontline staff in the development and implementation process and also recommends careful postimplementation monitoring for errors and near misses associated with new technology.

The General Assembly of Pennsylvania. HB957 (2005).

This bill calls for a prohibition of mandatory overtime and limiting the work week to 12 hours a day or 60 hours a week for non-supervisory health care employees in Pennsylvania.  It is presently under consideration by Pennsylvania's General Assembly.
Morrell D; Campbell T; Edwards J; Simpson G.
This addition to the Washington Patient Safety Act requires hospitals to develop and implement a staffing plan for nursing services. The plan addresses personnel issues for each patient care unit, requires hospitals to maintain records regarding patients and nursing care personnel, and authorizes the Department of Health to investigate complaints of staffing plan requirement violations and to conduct audits.

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.