International Journal for Quality in Health Care 13:339-340 (2001)
© 2001 International Society for Quality in Health Care
Patient Safety Alert |
‘High-alert’ medications and patient safety
This ‘Patient Safety Alert’ is the second in a series of periodic features in the Journal providing important information regarding the occurrence, management and prevention of sentinel events. A ‘sentinel event’ is an unexpected occurrence involving death or serious physical or psychological injury, or the risk of such injury. This risk includes any variation in a care provision process, where recurrence of the variation would carry significant likelihood of a serious adverse outcome. Such events are called ‘sentinel’ because they signal the need for immediate investigation and response.These articles are reprinted here with permission of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and are based on articles published by JCAHO in the publication ‘Sentinel Event Alert’ which appears on the JCAHO website at www.jcaho.org.
In 1996 JCAHO established a Sentinel Event Policy designed to encourage health care organizations to self-report health care errors. In the ensuing years JCAHO has developed and implemented a procedure for recording, assembling and analyzing the data provided in these reports. Application of this carefully formulated process – termed a ‘root cause analysis’ – for identifying the underlying causes of the performance variation or adverse event provides a means for structured investigation of the occurrence and for improvement of systems to prevent reoccurrence.
Data reported to the JCAHO under the Sentinel Event Policy by JCAHO-accredited health care organizations and by outside experts and organizations provide the basis for this series of Alerts.
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