Almost 8,000 total sentinel events have been reported to TJC since 1995. The majority of reports were submitted by hospitals (64%), 62% of the total reports resulted in patient death, and the most prevalent types of events reported through this voluntary reporting system are wrong-patient, wrong-site, or wrong-procedure, and unintended retention of a foreign body. Leadership, human factors and communication were identified as the most frequently identified root cause of such events.
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