Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix.

OBJECTIVES: The goal of sentinel event (SE) analysis is to prevent recurrence. However, the rate of SEs has remained constant over the past years. Research suggests this is in part due to the quality of recommendations. Currently, standards for the selection of recommendations are lacking. Developing a method to grade recommendations could help in both designing and selecting interventions most likely to improve patient safety. The aim of this study was to (1) develop a user-friendly method to grade recommendations and (2) assess its applicability in a large series of Dutch perioperative SE analysis reports. METHODS: Based on two grading methods, we developed the recommendation improvement matrix (RIM). Applicability was assessed by analysing all Dutch perioperative SE reports over a 12-month period. After which interobserver agreement was studied. RESULTS: In the RIM, two elements are crucial: whether the recommendation intervenes before or after an SE and whether it eliminates or controls the hazard. Applicability was evaluated in 115 analysis reports, encompassing 161 recommendations. Recommendation quality varied from the highest, category A, to the lowest, category D, with category A accounting for 44%, category B for 35%, category C for 2% and category D for 19% of recommendations. There was a fair interobserver agreement. CONCLUSION: The RIM can be used to grade recommendations in SE analysis and could possibly help in both designing and selecting interventions. It is relatively simple, user-friendly and has the potential to improve patient safety. The RIM can help formulate effective and sustainable recommendations, a second key objective of the RIM is to foster and facilitate constructive dialogue among those responsible for patient safety.

The next step in learning from sentinel events in healthcare.

OBJECTIVE: The aim of this study was to evaluate the current status of handling and learning from sentinel events (SEs) in Dutch academic hospitals and to develop a basis for the first steps in a joint and transparent approach to improve learning from SEs. DESIGN: Survey by the Netherlands Federation of University Medical Centres (NFU) as part of the project 'Quality-based Governance'. PARTICIPANTS AND SETTING: All eight Dutch University Medical Centres (UMCs). RESULTS: Three methods are used to identify the root cause of SEs: the Systematic Incident Reconstruction and Evaluation, Prevention and Recovery Information System for Monitoring and Analysis or TRIPOD method. Experts with different backgrounds are involved in the analysis of SEs. UMCs have different policies regarding the selection of recommendations for implementation. Some UMCs implement all recommendations formulated by the analysis team and in some UMCs the head of the involved department selects recommendations for implementation. No predetermined criteria have been established for this selection. Most UMCs confirm that similar SEs reoccur, which might be due to the quality of the analysis of the SEs or the quality of the recommendations. CONCLUSION: There is a large variety in handling SEs in Dutch academic hospitals and standards for the selection of recommendations are lacking. A next step to decrease the number of (similar) SEs lies in a joint and transparent approach to objectively assess recommendations and further define strategies for successful implementation. Selecting high-quality recommendations for implementation has the potential to lead to a decrease in the number of (similar) SEs and increase in the quality and safety of Dutch healthcare.

[Learning from incidents in healthcare: the value of incident investigation and improvement measures]. / Leren van incidenten in de zorg.

Incidents in healthcare are often followed by an investigation to find out what happened and how it was possible for them to happen. It is often difficult to find good answers to these questions, partly because it is usually not possible for complex reality to be described in simple cause-and-effect reconstructions. Another objective of incident investigations is the prevention of incident reoccurrence. In this respect, answers are not simple either, as it is difficult to think of improvement measures that are both effective and easy to implement. As a result, incident reporting and investigation do not automatically lead to prevention of incident reoccurrence. It is, however, possible to recommend some measures that lead to better investigations and effective improvement measures after incidents.