TAILIEUCHUNG - The Joint Commission Sentinel Event Alert

In this paper, we present a distributed location discovery frame- work, called Sextant, that extracts geographic constraints fromalready- present wireless radios and uses these constraints to infer node and event location with high accuracy. Sextant operates by setting up a system of relative geographic constraints among the network par- ticipants based on network connectivity and solving this system in a distributed and efficient manner with the aid of absolute position information provided by a small number of landmarks. A landmark is a node whose absolute position is known; Sextant landmarks can be cheap static nodes whose positions are fixed, or they may be mo- bile nodes equipped with dedicated hardware,. | The Joint Commission Sentinel Event Alert A complimentary publication of The Joint Commission Issue 49 August 8 2012 Safe use of opioids in hospitals Published for Joint Commission accredited organizations and interested health care professionals Sentinel Event Alert identifies specific types of sentinel events describes their common underlying causes and suggests steps to prevent occurrences in the future. Accredited organizations should consider information in an Alert when designing or redesigning relevant processes and consider implementing relevant suggestions contained in the Alert or reasonable alternatives. Please route this issue to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to The Joint Commission. To receive by e-mail or to view past issues visit . While opioid use is generally safe for most patients opioid analgesics may be associated with adverse effects 1 2 3 the most serious effect being respiratory depression which is generally preceded by 5 6 Other common adverse effects associated with opioid therapy include dizziness nausea vomiting constipation sedation delirium hallucinations falls hypotension and aspiration 7 Adverse events can occur with the use of any opioid among these are fentanyl hydrocodone hydromorphone methadone morphine oxycodone and sufentanil. While there are numerous problems associated with opioid use including underprescribing overprescribing tolerance dependence and drug abuse this Alert will focus on the safe use of opioids that are prescribed and administered within the inpatient hospital setting. The Joint Commission recognizes that the emergency department presents unique challenges that should also be addressed by the hospital but may not be directly addressed in this Alert. This Alert will provide a number of actions that can be taken to avoid the unintended consequences of opioid use among hospital .

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