The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) is responsible for assessing
the quality of healthcare delivery and certifying an organization, such as a hospital, is fit to deliver its
services. As part of this work, JCAHO compiles statistics and promotes best practices.
This graph shows the result of a JCAHO
analysis of root causes of 3548 sentinel events, occurring over a
10-year period. Most sentinel events are found to depend on multiple failures. However, when death or a severe
outcome occurs, almost 2/3 of the time communication is identified as the cause, or one of the key causes.
The purpose of communication is to create shared understanding - about the patient, and about what needs to
be done. In short, communication is a highly visible and important type of coordination. Each root cause shown
here is really a kind of coordination failure within the current team of caregivers. It can be a failure in the
real-time provision of care. But it is also a factor in the organizational arrangements (resources, training,
etc.) that create the context for communication and coordination of care.
Many of these causes have a direct relationship with the quality of
handover. Further, we conclude from
this analysis of sentinel events that
healthcare IT (e.g., EMR, CPOE)
in its current form does not address all these factors.