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A complimentary publication of The Joint …

* The reporting of most sentinel events to The Joint commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. Published for Joint commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences.

Sentinel Event Alert. Issue 55 Page 2 . www.jointcommission.org. Actions suggested by The Joint Commission . The Joint Commission recommends the following

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