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The Joint Commission disseminates "sentinel event alerts" identifying specific sentinel events, their underlying causes, and steps to prevent recurrence. [5] Further nursing research is ongoing at a number of "magnet" hospitals in the United States, especially to reduce the number of patient falls that may lead to sentinel events.
The Joint Commission Goal 2 states that "ineffective communication is the most frequently cited root cause for sentinel events, [3]" and requires that hospitals "implement a standardized approach to hand-off communications, including an opportunity to ask and respond to questions". [4]
The United States-based Joint Commission's sentinel event reports 80 alarm-related deaths and 13 alarm-related serious injuries over the course of a few years. On April 18, 2013, the Joint Commission issued a sentinel event alert that highlighted the widespread problem of alarm fatigue in hospitals.
The National Patient Safety Goals is a quality and patient safety improvement program established by the Joint Commission in 2003. The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety. [1] [2]
A 2008 Sentinel Event Alert from the U.S. Joint Commission, the organization that accredits American hospitals to provide healthcare services, states, 'As health information technology (HIT) and 'converging technologies'—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations, users must ...
The International Patient Safety Goals (IPSG) were developed in 2006 by the Joint Commission International (JCI). The goals were adapted from the JCAHO's National Patient Safety Goals. [1] Compliance with IPSG has been monitored in JCI-accredited hospitals since January 2006. [1]
A never event is the "kind of mistake (medical error) that should never happen" in the field of medical treatment. [1] According to the Leapfrog Group never events are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability." [2]
The Joint Commission's Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the root cause of over half the serious adverse events in accredited hospitals. [51]