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Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert #47. August 24, 2011.
The Joint Commission issues Sentinel Event Alerts periodically to highlight emerging patient safety issues and stimulate innovative approaches to addressing these threats. The overuse of diagnostic imaging, particularly computed tomographic (CT) scans, poses patient safety risks due to excess radiation exposure. More than 70 million CT scans are performed in the United States every year, and the radiation exposure from these scans may lead to thousands of cancer-related deaths. This alert reviews specific strategies organizations should take to minimize radiation risks, including educating physicians on appropriate test utilization, standardizing equipment and radiation dosage, and promoting a culture of safety. An AHRQ WebM&M commentary discusses factors that may contribute to overutilization of diagnostic imaging, with consequent short- and long-term risks to patients.
Journal Article > Commentary
Guenter P, Hicks RW, Simmons D, et al. Jt Comm J Qual Patient Saf. 2008;34:285-292.
This article describes factors contributing to errors in enteral nutrition delivery and offers strategies to prevent medical tubing misconnections.
Journal Article > Commentary
Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.
Simmons D, Phillips MS, Grissinger M, Becker SC. Jt Comm J Qual Patient Saf. 2008;34:293-296.
Based on reports received through numerous national organizations, this article provides public policy recommendations for preventing certain tubing misconnections.
Sentinel Event Alert. April 3, 2006;(36):1-3.
This alert summarizes types of tubing misconnections reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and recommends 10 strategies to prevent their occurrence.
Journal Article > Organizational Policy/Guidelines
Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group.
Heinemann L, Fleming GA, Petrie JR, Holl RW, Bergenstal RM, Peters AL. Diabetes Care. 2015;38:716-722.
Insulin is a high-alert medication that can lead to harm if incorrectly administered. Insulin pump problems can be caused by human, mechanical, or drug stability failures. This policy statement describes ways to use adverse event data, manufacturer information, and technical specifications to enhance the safety of insulin therapy.
Legislation/Regulation > Government Resource
Safety considerations to mitigate the risks of misconnections with small-bore connectors intended for enteral applications.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February 11, 2015.
Information Exchange System Alert. Geneva, Switzerland: World Health Organization; July 18, 2007.
This international announcement provides guidance on the safe administration of the chemotherapeutic agent vincristine.
Federal Register. April 10, 2006;71:18039-18053.
The U.S. Food and Drug Administration (FDA) is proposing to amend good manufacturing practice to include several strategies for minimizing medical gas-related patient safety incidents. The proposal is open for public comment through July 10, 2006.