Sentinel Event Alert Newsletters
Sentinel Event Alerts have been issued on the following events
- December 14, 2011
Issue 48: Health care worker fatigue and patient safety - September 1, 2011
Issue 47: Radiation risks of diagnostic imaging - November 17, 2010
Issue 46: A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department - June 3, 2010
Issue 45: Preventing violence in the health care setting - January 26, 2010
Issue 44: Preventing Maternal Death - August 27, 2009
Issue 43: Leadership committed to safety - December 11, 2008
Issue 42: Safely implementing health information and converging technologies - September 24, 2008
Issue 41: Preventing errors relating to commonly used anticoagulants - July 9, 2008
Issue 40: Behaviors that undermine a culture of safety - April 11, 2008
Issue 39: Preventing pediatric medication errors - February 14, 2008
Issue 38: Preventing accidents and injuries in the MRI suite - September 6, 2006
Issue 37: Preventing adverse events caused by emergency electrical power system failures - April 3, 2006
Issue 36: Tubing misconnections—a persistent and potentially deadly occurrence - January 25, 2006
Issue 35: Using medication reconciliation to prevent errors - July 14, 2005
Issue 34: Preventing vincristine administration errors - December 20, 2004
Issue 33: Patient controlled analgesia by proxy - October 6, 2004
Issue 32: Preventing, and managing the impact of, anesthesia awareness - August 31, 2004
Issue 31: Revised guidance to help prevent kernicterus - July 21, 2004
Issue 30: Preventing infant death and injury during delivery - June 24, 2003
Issue 29: Preventing surgical fires - January 22, 2003
Issue 28: Infection control related sentinel events - September 6, 2002
Issue 27: Bed rail-related entrapment deaths - June 17, 2002
Issue 26: Delays in treatment - February 26, 2002
Issue 25: Preventing ventilator-related deaths and injuries - December 5, 2001
Issue 24: A follow-up review of wrong site surgery - September 1, 2001
Issue 23: Medication errors related to potentially dangerous abbreviations - August 1, 2001
Issue 22: Preventing needlestick and sharps injuries - July 1, 2001
Issue 21: Medical gas mix-ups - June 1, 2001
Issue 20: Exposure to Creutzfeldt-Jakob Disease - May 1, 2001
Issue 19: Look-alike, sound-alike drug names - April 1, 2001
Issue 18: Kernicterus threatens healthy newborns - March 1, 2001
Issue 17: Lessons Learned: Fires in the Home Care Setting - February 27, 2001
Issue 16: Mix-up Leads to a Medication Error - November 30, 2000
Issue 15: Infusion Pumps: Preventing Future Adverse Events - July 12, 2000
Issue 14: Fatal Falls: Lessons for the Future - April 21, 2000
Issue 13: Making an Impact on Health Care - February 4, 2000
Issue 12: Operative and Post-Operative Complications: Lessons for the Future - November 19, 1999
Issue 11: High-Alert Medications and Patient Safety - August 30, 1999
Issue 10: Blood Transfusion Errors: Preventing Future Occurrences - April 9, 1999
Issue 9: Infant Abductions: Preventing Future Occurrences - November 18, 1998
Issue 8: Preventing Restraint Deaths - November 6, 1998
Issue 7: Inpatient Suicides: Recommendations for Prevention - August 28, 1998
Issue 6: Lessons Learned: Wrong Site Surgery - July 24, 1998
Issue 5: Board Votes To Increase Time Frame For Submitting Root Cause Analysis - May 11, 1998
Issue 4: Examples Of Voluntarily Reportable Sentinel Events - May 1, 1998
Issue 3: Board of Commissioners Affirms Support For Sentinel Event Policy - March 20, 1998
Issue 2: Board To Review Modifications To Sentinel Event Procedures - February 28, 1998
Issue 1: New Publication: Medication Error Prevention -- Potassium Chloride
