Sentinel event “most common” can change by reporting year and classification approach. Recent summaries of 2023 sentinel event reporting indicatefallswere the most frequently reported category in that dataset, with wrong surgery and unintended retention also high-ranking. Risk management objectives treat this as a dynamic signal: the organization should use current event data, internal trends, and unit-specific hazards to prioritize controls. Falls prevention requires layered interventions—risk stratification, mobility support, medication review, environmental controls, and post-fall huddles to learn and redesign. Leaders should avoid over-fixating on one historical “most common” event type and instead use current surveillance to target the biggest preventable harm burdens.
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