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•PR: – Sentinel Event Statistics for 2012[®] [Pearl: CJCP, GB, LDR, MDx, RNx] Perspectives, February 2013, Pg 1, Vol 33, #3 Although it is estimated that less than 2% of all sentinel events (SE) are reported, TJC did review 901 of them last year. This article reports the most frequent SEs and root causes (RC) based upon those reviews. The Top 10 SEs continue to include Suicide (#4/10) and Falls (#6/10). The Top 10 RCs continue to include Human factors (e.g., fatique/distraction #1/10), Leadership (e.g., PI infrastructure/policies #2/10), Communication (e.g., among staff and pts #3/10), Assessment (e.g., pt observation #4/10), Information Management (e.g., pt identification #5/10),and the Physical Environment (e.g., emergency management #6/10). |
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