The Joint Commission Releases Sentinel Event Statistics

August 12, 2011    |   By: Calevir

Almost 8,000 total sentinel events have been reported to TJC since 1995.   The majority of reports were submitted by hospitals (64%), 62% of the total reports resulted in patient death, and the most prevalent types of events reported through this voluntary reporting system are wrong-patient, wrong-site, or wrong-procedure, and unintended retention of a foreign body.  Leadership, human factors and communication were identified as the most frequently identified root cause of such events.

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PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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