8 | Joint Comission • Sentinel Event Alerts that identify specific sentinel events (an unexpected death or serious physical or psychological injury) or patient safety problems, describes their common underlying causes, and suggests steps to prevent the occurrence of these events. Much of the information and guidance provided in these Alerts is drawn from The Joint Commission’s Sentinel Event Database, one of the nation’s most comprehensive voluntary reporting systems for serious adverse events in health care. Alerts have addressed important issues such as health care worker fatigue, maternal deaths, medication mix-ups, and patient suicides. • The Speak Up program provides patients with free safety tips on a variety of health care topics including surgery, infection control, medicines, follow-up care, medical tests, patient rights, understanding caregivers, pain management, child safety, and diabetes and dialysis care in the hospital. The Joint Commission is also committed to providing the public with reliable information about the health care provided by our accredited and certified organizations. The Quality Check website and the annual report, Improving America’s HospiAnn Scott Blouin, Ph.D., RN, FACHE, Executive Vice President, Customer Relations
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