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.