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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 Joint Commission is one of the most widely used accreditation organizations. The International Society for the Quality in Healthcare (ISQua) is the umbrella organization responsible for accrediting the Joint Commission accreditation scheme in the US and Accreditation Canada International, as well as accreditation organizations in the United ...
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. [66]
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]
A sentinel surveillance system is used to obtain data about a particular disease that cannot be obtained through a passive system such as summarizing standard public health reports. Data collected in a well-designed sentinel system can be used to signal trends, identify outbreaks and monitor disease burden, providing a rapid, economical ...
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]