Human factor issues were the most often cited root cause of sentinel events for three straight years, according to a review presented April 15 by the Joint Commission. Human factors also topped the list for operative/postoperative complications, radiation overdose and equipment-related events over a 10-year span.  

Organizations report sentinel events and their root causes voluntarily to the Joint Commission, which reviews the data, provides feedback and stores the events and root causes in a de-identified database. The reviewers assess reasons for the failure and opportunities to implement interventions. Often several root causes contribute to the reported sentinel event.

In 2011, the commission received 1,243 reports of sentinel events, with 899 linked to human factors. They defined human factors as staffing levels, skill mix, in-service education, staff and resident supervision, credentialing, fatigue, distractions and other impediments.

Human factors were the most cited cause in 2012 (614 or 901 events) and 2013 (635 of 887 events) as well.

Leadership was the second most common root cause in 2011 and 2012, and placed third in 2013. Leadership includes variables such as organizational planning, culture, resource allocation and collaboration. Communication came in third in 2011 and 2012, and was second in 2013.     

In an analysis of root causes for operative and post-operative complications, the commission found human factors followed by communication were the most frequently cited root causes between 2004 and 2013. The sentinel events resulted in either death or permanent loss of function.

Human factors and leadership issues shared the top for radiation overdose events, which were either a cumulative dose of more than 1,500 rads to a single field, delivery of radiotherapy to the wrong body region or more than 25 percent above the planned dose.

Human factors followed by leadership ranked No. 1 and No. 2 for medical equipment-related events that resulted in death or permanent loss of function.

Other root causes evaluated by the Joint Commission included physical environment, assessment, information management, operative care, continuum of care and medication use. Only a fraction of the total number of sentinel events in the U.S. get reported to the commission, so the findings do not reflect actual frequency of events.

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