Friday, 25th August
16:00-17:00

Sentinel events can be a predictor of system level risks. Aggregated and de-identified data from the 2014 to 2016 Joint Commission and Joint Commission International global database identified six most frequent root causes of sentinel events. Analysis of the reported sentinel events and root causes can help identify solutions prevent events from occurring on a system and hospital level. Standards can help organizations provide a safer environment for their patients.

After this session, participants will be able to:

• Identify and understand the six most frequent root causes of sentinel events for many health systems across the world.


• Understand how the identified root causes present system-level risks in day-to-day operations of healthcare providers.


• Address and provide solutions to resolve identified risks from a system improvement perspective and a standards framework.

Paul Chang, Vice President, Accreditation, Standards and Measurement Joint Commission International; USA
Claudia Jorgenson, Director, Standards Development, Interpretation, and Clinical Operations, Joint Commission International (JCI); USA