August 31, 2009 | Mark Paradies

Monday Accident and Lessons Learned: JCAHO Data Points to “Inadequate and Ineffective Leadership” as a “Contributing Factor” in 50% of Healthcare Sentinel Events – Does Your Management Need New Knowledge?

I’m not making this headline up.


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) wrote it in the first paragraph.

The toll of this inadequate leadership is staggering – about 50,000 deaths per year. (Taking the estimate of deaths in the US from the Institute of Medicine report and multiplying it by 50%).

Another way to think about this is that perhaps 1/2 of the 5708 registered hospitals in the US have inadequate leadership. That’s 2604 hospitals that need to improve their leadership and probably should be concentrating on learning advanced root cause analysis and performance improvement best practices.

We’ve always sent information about the Eliminating Healthcare Sentinel Events Best Practice Track and TapRooT® Training to risk management, patient safety, and quality improvement professionals at hospitals. Maybe we should be sending the information to hospital administrator to reach the top of the leadership pyramid?

If you think your administrators need to know more about root cause analysis and preventing sentinel events, pass our newsletters along. Or sign them up to get our newsletters monthly at:

Also, pass along information about the Eliminating Healthcare Sentinel Events Best Practice Track at the TapRooT® Summit. They will be amazed at what they learn. See the schedule by clicking on the appropriate button on the left at:

There is still time to get them registered! And they will thank you when they return.

Don’t let your management cause a fatal sentinel event. Learn a lesson from the JCAHO database and get your hospital administrators educated now!

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