The New Joint Commission Sentinel Event Pertaining to Prolonged Fluoroscopy

摘要

The Joint Commission (JC), previously called JCAHO, defines sentinel events as follows: A sentinel event is an unexpected occur-rence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. [1]