The Joint Commission tracks all reported sentinel events and categorizes them by root cause. Do you know the most common causes of preventable and catastrophic error in healthcare? The same three root causes top the lists every year! What are these pervasive causes?

For three years in a row, topping the charts:

Human Factors



In patient safety conversations, we hear a lot about medication errors, monitoring and vigilance, and coordination among care among teams. Yet, perhaps surprisingly, these were at the bottom of the list for all three of the same years. I am often asked why I focus on so-called “soft” skills like decision making and human factors, instead of “real” medicine or “hard science.” I do so because these skills (and deficits) apply ubiquitously to all healthcare situations, and heavily influence the success or failure of healthcare teams. Apparently, the Joint Commission agrees. What are your favorite tools and strategies to reduce the impact of human factors and team based errors in your organization? Tweet me, leave a comment, or send me an email!



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