Top 10 causes of anesthesia-related sentinel events

The Joint Commission released 10 years of sentinel event root cause data reported to the organization between 2004 and the second quarter of 2014. The following are the top causes of anesthesia-related sentinel events (104 events total), based on a decade of Joint Commission data.

Editor's Note: More than one root cause could be named for each sentinel event. All percentages are rounded to the nearest percentage point.

1. Anesthesia care: 62 percent

2. Assessment: 56 percent

3. Human factors: 55 percent

4. Communication: 53 percent

5. Leadership: 46 percent

6. Information management: 15 percent

7. Physical environment: 15 percent

8. Medication use: 14 percent

9. Continuum of care: 9 percent

10. Care planning: 6 percent (anesthesia, nfp)

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