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Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by healthcare regulatory authorities. Sentinel events are identified under The Joint Commission (TJC) accreditation policies to help aid in root cause analysis and to assist in development of preventive measures. The ...
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 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 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]