Top 10 Root Causes of Sentinel Events

Tags: patient safety | root causes | sentinel events | The Joint Commission

The Joint Commission reported the top 10 root causes of reported sentinel events in 2012.

Root causes are "the fundamental reason(s) for the failure or inefficiency of one or more processes," according to The Joint Commission. Healthcare organizations that report sentinel events to The Joint Commission are required to share their root causes analysis, which is then reviewed by a Joint Commission clinician. Most events have multiple root causes, according to The Joint Commission.


There were a total of 901 sentinel events reported to The Joint Commission in 2012. Here are the 10 most common root causes of these events:

1. Human factors
2. Leadership
3. Communication
4. Assessment
5. Information management
6. Physical environment
7. Continuum of care
8. Operative care
9. Medication use
10. Care planning

The Joint Commission noted, "The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time."

More Articles on The Joint Commission:

Top 10 Sentinel Events Reviewed by Joint Commission in 2012
The Joint Commission Appoints Dr. Daniel Castillo Medical Director of Healthcare Quality Evaluation
John M. Eisenberg Patient Safety and Quality Award Recipients Announced