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.
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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