title: Getting to the bottom of a sentinel event.
authors.affiliation: Patient Care Services, Fairview Hospital, Berkshire Health Systems, Great Barrington, MA 01230, USA. dhutchinson@bhs1.org
authors.forename: D
authors.initials: D
authors.lastname: Hutchinson
mesh_terms: D006801:Humans; D010607:Pharmacy Service, Hospital; D012308:Risk Management