Circulation 107,515 • Volume 27, No. 3 • Winter 2013   Issue PDF

The Joint Commission Sentinel Event Alert #49 Motivates Monitoring Strategies

Frank Overdyk, MSEE, MD

To the Editor

The Joint Commission (JC) Sentinel Event Alert #49 on the safe inpatient use of opioids (issued August 2012) has motivated many hospital administrators and medical staff to explore monitoring strategies that are aligned with its recommendations.1 The APSF has been a catalyst in driving awareness on the dangers of parenteral opioids, convening 2 conferences and numerous articles in its
Newsletter to this serious patient safety issue since 2006. The JC Sentinel Event Alert specifically calls out inadequate monitoring as the root cause of many opioid-related adverse events and references the 2012 APSF recommendations for improved monitoring of patients receiving opioids on medical/surgical wards.2 The following table reconciles the monitoring recommendations from the JC Sentinel Event Alert with those from the APSF as they relate to patient monitoring in an effort to highlight similarities and differences, and guide electronic monitoring “best practice.”

Dos and Don'ts

Frank Overdyk, MSEE, MD
North American Partners in Anesthesia (NAPA)
Professor, Hofstra North Shore-LIJ School of Medicine
Melville, New York


  1. Accessed 12/31/2012.
  2. Accessed 12/31/2012.