According to the Joint Commission, the majority of wrong-patient, wrong-site or wrong-procedure sentinel events had multiple root causes, including the following 10 most common root causes.
1. Leadership — contributed to 908 wrong-patient, wrong-site or wrong-procedure sentinel events
2. Human factors — 772
3. Communication — 759
4. Assessment — 398
5. Information management — 390
6. Operative care — 353
7. Physical environment — 99
8. Patient rights — 66
9. Anesthesia care — 56
10. Continuum of care — 39
To read more about how the root causes were defined for the report, click here.
More articles on wrong-site errors:
Top 10 sentinel events in 2014
Top 9 risk factors leading to wrong-site surgery
How safe is your OR? 8 things to consider
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