Yet in the same time period they reported to the state only 402 sentinel events.

It may be more important to regard each death as a sentinel event.

A sentinel event is an incident which results in death or serious physical harm.

As a result the hospital initiated an internal sentinel event investigation.

Maternal mortality is a sentinel event to assess the quality of a health care system.

Such scheduling gaps leave patients unattended and at risk for sentinel events.

The analysis performed will address trends, sentinel events, etc with respect to the incidents themselves.

"We thought we were saying, 'You tell us about your sentinel events, and we'll work together on the solutions.' "

In the case of medication incident data, reported cases will undergo a risk assessment to detect sentinel events.

Educational materials to help patients prevent medical errors, sentinel event alerts and other resources are provide on the internet.

The program focuses on sentinel events and those events receiving the highest safety assessment codes.

Surveillance is used to identify sentinel events, such as outbreaks of diseases, that may require immediate policy decisions concerning public health.

In 2002, the Joint Commission began requiring disclosure to patients in sentinel event cases.

A policy for routine drug-alcohol testing for all physicians involved with a sentinel event leading to patient death.

The commission's finding utilized its "sentinel event" reporting system, a computer database that includes 1,609 reports of patient deaths and injuries since 1996.

"These epidemics are sentinel events for the crumbling of our public health services," Dr. Wood said.

These are reproduced in the Sentinel Event Investigation papers.

I asked, “In how many of these sentinel events did someone know something was wrong and didn’t speak up, or spoke up and wasn’t heard?”

Advantages of reporting sentinel events to The Joint Commission are:

Some of these cancers may therefore represent "sentinel events" providing a warning of "new" or changing exposures.

Each accredited organization is encouraged, but not required, to report any sentinel event to The Joint Commission.

The two event sentinel events are:

The WHO will also collaborate in international registries for sentinel events after living organ donation.

The cases are among the 241 so-called ``sentinel events" severe enough to cause death or significant harm to patients reported to the commission during the 2012-13 year.

They discuss the use of these techniques to investigate a sentinel event in which a child died after receiving an overdose of digoxin.