The following are the top 10 root causes for infection-related sentinel events, which result in death or permanent loss of function, according to data collected by The Joint Commission. The majority of events had more than one root cause, according to the data.
1. Leadership (51 percent) — Subcategories include organizational planning or culture, service availability, resource allocation, leadership collaboration, complaint resolution, standardization, integration of services, performance improvement, medical staff organization and nursing leadership.
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2. Human factors (49 percent) — Subcategories include staffing levels, staffing skill mix, staff orientation, staff competency and supervision, staff credentialing, staff peer review and other (rushing, fatigue, distraction, complacency and bias).
3. Communication (48 percent) — Subcategories include oral, written, electronic, among staff, physicians or administration and with patient or family.
4. Surveillance, prevention and control of infection (48 percent) — Subcategories include sterilization, contamination and universal precautions.
5. Assessment (34 percent) — Subcategories include planning, monitoring and discharge.
6. Information management (21 percent) — Subcategories include information management needs assessment, confidentiality or security of information, definitions, availability of information, technical systems, identification of patient, medical records and data aggregation.
7. Care planning (17 percent) — Subcategories include planning and collaboration.
8. Physical environment (17 percent) — Subcategories include hazard and security systems and safety, emergency management, equipment management and utilities management.
9. Continuum of care (10.2 percent) — Subcategories include access to care, setting of care, continuity of care, patient transfers and discharge.
10. Medication use (10.2 percent) — Subcategories include formulary, storage and control, labeling, ordering, preparation and distribution, administration and patient monitoring.
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