The Joint Commission: 10 most frequently identified root causes of sentinel events

In 2014, human factors were the most frequently identified root cause of sentinel events, according to "Sentinel Event Data Root Causes by Event Type 2004-2014," released by The Joint Commission.

Here are the 10 most frequently identified root causes:

•    Human factors
•    Leadership
•    Communication
•    Assessment
•    Physical environment
•    Information management
•    Care planning
•    Health information technology-related causes
•    Operative care
•    Continuum of care

Sentinel events are reported to The Joint Commission voluntarily by an accredited organization or reported via the complaint process. Most events have multiple root causes.

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