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The Joint Commission.
Since 1998, The Joint Commission has issued sentinel event alerts in response to unexpected incidents involving death or serious physical or psychological injury (or risk thereof). These events are identified as sentinel due to the gravity of the injury and the need for immediate investigation and response. The goal is often to determine the root causes involved and provide recommendations for future prevention. The Sentinel Event Alert Web site includes a complete library of previous sentinel event alerts, along with related statistics, podcasts, forms, tools, policy and procedures, and a frequently asked questions section reviewing selected recent topics.