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- Computerized Adverse Event Detection
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. January 26, 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 newly released alert targets prevention of maternal death. Whereas a past alert focused on death and injury among newborns, this one highlights the leading causes and prevention of maternal death, including failure to manage blood pressure, paying attention to vital signs following cesarean section, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments.
Cases & Commentaries
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John Q. Young, MD, MPP; July 2011
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.