JCAHO SENTINEL EVENT INFORMATION Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies the most frequently occurring sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.       During the on-site survey of accredited organizations, JCAHO surveyors assess the organization's familiarity with and use of Sentinel Event Alert information. Organizations are expected to:     (1) review each Sentinel Event Alert,     (2) consider the suggestions, as appropriate to the organization's services, and     (3) implement the suggestions, or reasonable alternatives, or provide a reasonable explanation for not implementing relevant changes.       Please route this issue to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to the Joint Commission on Accreditation of Healthcare Organizations.
	JCAHO articles regarding Sentinel Events		Applies to BHC?	Leadership Review	Action Required?
1	27-Jun-01	Sentinel Event Statistics	yes	SERC - PIC	no
2		Glossary	yes	SERC - PIC	no
3		Reporting of Medical/Health Care Errors	yes	SERC - PIC	yes
	Sentinel Event Alert Policies & Procedures		Applies to BHC?	Leadership Review	Action Required?
	Issue Date	Topic
4	20-Mar-98	Board To Review Modifications To Sentinel Event Procedures	yes	SERC - PIC
5	01-May-98	Board Approves Changes to Sentinel Event Policy and Procedures	yes	SERC - PIC
6	11-May-98	Accreditation Committee Approves Examples Of Voluntarily Reportable Sentinel Events	yes	SERC - PIC
7	24-Jul-98	Board Approves Changes to Sentinel Event Policy And Procedures	yes	SERC - PIC
	Sentinel Event Alert Issues		Applies to BHC?	Leadership Review	Action Required?
	Issue Date	Topic
8	27-Feb-98	Medication Error Prevention - Potassium Chloride
9	28-Aug-98	Lessons Learned: Wrong Site Surgery
10	06-Nov-98	Inpatient Suicides: Recommendations for Prevention
11	18-Nov-98	Preventing Restraint Deaths
12	30-Aug-99	Blood Transfusion Errors: Preventing Future Occurrences
13	19-Nov-99	High-Alert Medications and Patient Safety
14	04-Feb-00	Operative and Post-Operative Complications: Lessons for the Future
15	21-Apr-00	Making an Impact on Health Care
16	12-Jul-00	Fatal Falls: Lessons for the Future
17	30-Nov-00	Infusion Pumps:  Preventing Future Adverse Events
18	27-Feb-01	Mix-up Leads to a Medication Error
19	20-Mar-01	Lessons Learned: Fires in the Home Care Setting
20	01-Apr-01	Kernicterus Threatens Healthy Newborns
21	01-May-01	Look-alike, Sound-alike Drug Names
22	01-Jun-01	Exposure to Creutzfeldt-Jakob Disease