The Joint Commission has released 10 years of sentinel event root cause data. The data covers events reported to the organization between 2004 and the second quarter of 2014.
Here are the top causes of anesthesia-related, operative or postoperative complication, unintended retention of surgical object and wrong-patient, wrong-patient, wrong-procedure sentinel events, 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.
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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Here are the top causes of anesthesia-related, operative or postoperative complication, unintended retention of surgical object and wrong-patient, wrong-patient, wrong-procedure sentinel events, 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.
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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Joint Commission posts diagnostic imaging standards for comment