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Sentinel Events are defined as serious adverse events that cause death or severe injury to the patient and result in loss of trust in the national healthcare system by citizens.

The surveillance of sentinel events which has been well under way in other countries, is an important role of public health. It is an indispensible tool for the prevention of such events and for the promotion of patient safety.

It is for this reason that the Ministry of Health has elaborated, with the technical support of “Gruppo di lavoro valutazione degli approcci metodologici in tema di rischio clinico", this protocol for monitoring sentinel events with the objective to provide Regions and the Healthcare Trusts an unambiguous method of surveillance and management to be applied throughout the national territory, guaranteeing LEA essential levels of assistance.

The present protocol represents an updated version of previous ones (updated as of July 2009) which has been reviewed and agreed upon by the Regions and Autonomous Provinces for Patient Safety.

The protocol contains:

1. A descriptive form of the sentinel events object of monitoring which is to supply the necessary information in order to define and classify the event;
2. Sentinel event reporting form;
3. Cause and contributing factors analysis form;
4. Plan of action to reduce risk, or rather the actions placed in act to prevent the reoccurrence of the event
   

Consult the unabridged version of the Protocol for sentinel event monitoring, updated July 2009:

• Protocol in pdf version (200 Kb)
• Protocol in doc version (400 Kb)

Sentinel Event List

1. Procedure performed to wrong patient
2. Surgery performed to wrong part of body (side, organ or part)
3. Erroneous procedure to correct patient
4. Instruments or other material retained in surgical site which requires successive interventions or ulterior surgery
5. Transfusion reaction consequent to ABO incompatibility
6. Death, coma or severe harm originating from error in pharmacologic therapy
7. Maternal death or severe illness correlated to labour and/or childbirth
8. Death or permanent disability in healthy newborn weighing > 2500 grams not correlated to congenital illness 
9. Death or severe bodily harm due to patient fall
10. Suicide or attempted suicide by patient in hospital
11. Violence performed on patients
12. Acts of violence resulting in injury to healthcare workers
13. Death or grievous bodily harm consequent to a malfunction with the transport system (intra-hospital and extra-hospital) 
14. Death or severe injury consequent to the incorrect attribution of a triage code by emergency services department or by (centrale operative 118) emergency telephone call centre
15. Sudden death or injury consequent to surgery
16. All other adverse events that cause death or grievous bodily harm to patient

The Ministry of Health has also made available The Sentinel Event Monitoring Protocol – Second Report (pdf, 100 Kb), updated October 2009.

For all other enquiries please contact:

Direzione Generale della Programmazione Sanitaria, dei Livelli di Assistenza e dei Principi Etici di Sistema
Ufficio III – Via G.Ribotta 5 - 00144 Roma