Recommendations for preventing sentinel events: results of a national cross-sectional survey in Italy

Abstract

Introduction. In 2005, the Italian Ministry of Health entrusted the National Agency for Regional Healthcare Services (Agenzia Nazionale per i Servizi Sanitari Regionali, AGENAS) with the task of monitoring the implementation of recommendations to prevent sentinel events, which are serious adverse events that can compromise patient safety. The aim is to provide Regions and healthcare facilities with a standardised method for managing these events. Currently, there are nineteen recommendations developed with the support of regional experts and other stakeholders.
Objective. This study assessed the applicability and implementation of these recommendations in Italy, also comparing data on the most frequently reported sentinel events. Materials and Methods. The study, conducted from March to October 2023, involved
all acute care, rehabilitation, and post-acute long-term care facilities, both public and private. A questionnaire was used to gather information on the applicability and implementation of the recommendations as of December 31, 2022. The data were analysed
using the statistical software Jamovi.
Results. 34.7% of the facilities found no recommendations applicable, while 18.4% considered all 19 recommendations. Regarding implementation, 35.5% did not implement any recommendations, while 11.3% implemented all 19. In particular, Recommendation 4
(“Prevention of patient suicide in hospital”) was not implemented by 16% of the facilities.
Conclusions. The applicability of the recommendations varies depending on the type of facility. The implementation rate is influenced by the diversity of participating facilities. The low implementation of Recommendation 4 suggests a need for further investigation
to understand the challenges faced.