Grading recommendations after sentinel events
The primary goal of the analysis of a sentinel event (SE) in healthcare is to prevent recurrence of similar events in the future. Really improving patient safety on the basis of these analysis has been proven challenging. The frequency of SEs, which are incidents that lead to death or serious harm to patients, has essentially remained unchanged in recent years. Improving patient safety after an SE is based upon a learning cycle. Analysis of the reported SE results ultimately in improvement measures which need to be implemented in order to improve safety. Not being able to complete this learning cycle will have impact on patient safety and the possible recurrence of similar SE. Research suggests that the lagging improvement of patient safety is at least in part due to the quality of the improvement recommendations proposed in SE analysis reports.
Criteria for recommendations after perioperative sentinel events - PubMed (nih.gov)
