Editor’s Note: More than one root cause could be named for each sentinel event. All percentages are rounded to the nearest percentage point.
Anesthesia-related sentinel events (104 events total)
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
Operative or postoperative complications (823 events total)
1. Human factors: 62 percent
2. Communication: 53 percent
3. Assessment: 48 percent
4. Leadership: 40 percent
5. Information management: 18 percent
6. Operative care: 13 percent
7. Physical environment: 11 percent
8. Care planning: 10 percent
9. Medication use: 9 percent
10. Continuum of care: 9 percent
Unintended retention of foreign objects (932 events total)
1. Leadership: 77 percent
2. Human factors: 65 percent
3. Communication: 63 percent
4. Operative care: 52 percent
5. Assessment: 24 percent
6. Physical environment: 21 percent
7. Information management: 15 percent
8. Continuum of care: 3 percent
9. Performance improvement: 2 percent
10. Care planning: 1 percent
Wrong-patient, wrong-site, wrong-procedure (1071 events total)
1. Leadership: 81 percent
2. Communication: 68 percent
3. Human factors: 67 percent
4. Information management: 36 percent
5. Assessment: 35 percent
6. Operative care: 32 percent
7. Physical environment: 9 percent
8. Patient rights: 6 percent
9. Anesthesia care: 5 percent
10. Continuum of care: 4 percent
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