•PR: – Sentinel Event Statistics for First Half of 2013[®] [REF: JCSC, LDR, PI, SFT] Perspectives, October 2013, Vol 33, #10, Pg 1  JCp1310_B1

Based on updated SE statistics through the first half of this year, the 10 most frequently reported events include Falls (#4), Suicide (#7), Assault/Rape/Homicide (#8) and Medication Errors (#9).   The 10 most commonly identified root causes  fell into the following categories:

• Human factors (e.g., effects on staff performance by fatigue or distraction)
• Communication (e.g., hand-off communication, patient education)
• Leadership (e.g., failure to plan/design adequate performance improvement processes)
• Assessment (e.g., ineffective observation processes, missed re-assessments)
• Information management (e.g., patient identification errors)
• Physical environment (e.g., inadequate management  of emergencies or hazardous materials)
• Care planning (e.g., inadequate treatment planning and coordination)
• Continuum of care (e.g., errors and/or omissions related to patient transfer and/or discharge)
• Medication use (e.g., problems related to storage/control or labeling)
• Operative care (e.g., problems related to blood use or patient monitoring)

Tip: Although it is estimated that less than 2% of all SE’s are probably being reported, leadership should periodically ask itself, if any of the frequent events are likely to occur in their facility and if so, use the root cause categories above to help proactively identify opportunities to reduce that risk.