Breakdown in communication stands out as the most common root cause of sentinel events because when essential information about a patient’s status, plan, or orders isn’t conveyed clearly and timely, errors are likely to follow. In the high-stakes environment of perioperative care, miscommunications during handoffs, during team interactions, or when escalating concerns can lead to wrong-site or wrong-procedure errors, delays in treatment, or failure to catch a deteriorating condition. Strengthening how information is exchanged—through standardized handoffs, read-backs, checklists, and a culture that encourages clarifying questions—addresses the most frequent pathway by which sentinel events occur. While not following policies and procedures can contribute to unsafe events and fear of reprisal can hinder speaking up, these factors are often manifestations of broader communication gaps. The pattern most consistently linked to sentinel events is that information isn’t shared clearly enough to support safe decisions.