Top 10 Identified Root Causes of Sentinel Events

The Joint Commission has identified the top 10 root causes of sentinel events reported from January to June 2013.

An organization reporting a sentinel event submits a root cause analysis to The Joint Commission, which reviews and discusses the causes with the organization. Here are the 10 most commonly identified root causes of the 446 sentinel events reported in the first half of 2013. The number of events attributed to each root cause is indicated; most events have more than one root cause. 


•    Human factors — 314. The human factors category relates to staffing levels and mix, peer review and other staff-related factors, such as fatigue and complacency.

•    Communication — 292. This refers to communication among any of the following groups: staff, physicians, administration, patients and patients' families.

•    Leadership — 276. Organizational planning, culture and leadership are included in this category.

•    Assessment — 246. Assessment includes patient assessment and care decisions.

•    Information management — 101. Information management includes data definitions, security, availability and medical records.

•    Physical environment — 70. Physical environment includes general safety and equipment management, among other factors.

•    Care planning — 49. Care planning includes planning and/or collaboration.  

•    Continuum of care — 48. Continuum of care includes access to care, continuity and patient transfers.

•    Medication use — 48. Medication use includes medication storage and control, ordering, administering and other medication-related tasks.

•    Operative care — 45. Operative care includes planning, blood use and/or patient monitoring.

The Joint Commission identified the same top 10 root causes in 2012, but in a different order. It noted, "These root cause data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of root causes or trends in root causes over time."

More Articles on Patient Safety:

Top 10 Sentinel Events Reviewed in First Half of 2013
8 Ways Vanderbilt University Medical Center Raised Hand Hygiene Compliance 

5 Leaders Address HAI Reduction at Senate Committee Hearing

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