What Are the Top Root Causes of Surgical Sentinel Events?

The following are the most common root causes between 2004 and 2013 for operative and postoperative complications, unintended retention of foreign objects and wrong-patient, wrong-site wrong-procedure sentinel events as reviewed by The Joint Commission. Sentinel events often have more than one cause, according to the data.

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Op/post-op complications:

Human factors — 62 percent

Communication — 53 percent
Assessment — 49 percent

Leadership — 40 percent

Information management — 19 percent

Operative care — 13 percent

Physical environment — 11 percent

Care planning — 10 percent

Medication use — 10 percent

Continuum of care — 8 percent

Unintended retention of foreign object:

Leadership — 80 percent

Human factors — 67 percent

Communication — 64 percent

Operative care — 54 percent

Assessment — 25 percent

Physical environment — 22 percent

Information management — 16 percent

Continuum of care — 3 percent

Performance improvement — 2 percent

Care planning — 1 percent

Wrong-patient, wrong-site wrong-procedure:

Leadership — 82 percent

Communication — 69 percent

Human factors — 69 percent

Information management — 36 percent

Assessment — 36 percent

Operative care — 32 percent

Physical environment — 9 percent

Patient rights — 6 percent

Anesthesia care — 5 percent

Continuum of care — 4 percent

To read more on the definitions of the root causes, download The Joint Commission’s presentation on the data.

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