68-606 / Sentinel Events Monitoring System

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Italian Ministry of Health


Incident reporting and learning system
Reporting and learning systems
GOP Description
Implementation level
Clinical settings
To monitor Sentinel Events occurred inside the hospitals
To have a Data Base containing a classification of sentinel events, to collect information about different kinds of SE and contributing factors. Also action plans to improve patient safety
All the patient receiving a health care services
Italian MoH defined a list of 16 different sentinel events to correctly classify them. When an adverse event occurs the Hospital fills out a specific form and sends it to the Region. The region check it and sends to the MoH trough a dedicated information flow.
The MoH has the Data Base of all the SE.
The MoH after the validation inserts it inside the Data Base.
Up to now the System has 16 different categories and we published a Recommendation for some of these sentinel events, but our intent is to have a Recommendation for each of these SE to avoid or reduce the risk for the patients.
This is a voluntary system of signalling.
We publish periodically a Report available on Ministry of Health web side (www.salute.gov.it)
Timeframe implementation
We start this activity during 2005 in a experimental way , and it was formalized by law in 2008, but is still improving
Implementation tools available
It is important to have an agreement between Government and Regions, share and disseminate the information with the stakeholders
Implementation cost
The implementation required an information flow nation wide, it was about 300.000 Euro for National Health System, to create the platform, the software and the training for the health care workers
Method used to measure the results
An increasing number of voluntary signalling means a great interest in this field, and the use of it.
Our data base contains about 1500 SE validated
The most frequent event is Patient Fall 22,26%, the second is Patient Suicide 15,67%.
Analysis of the results
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Sometime the health facility fill out the first form but the region doesn’t complete the procedure, and the System doesn’t insert the new event in the Data Base.
There is a cultural barrier for the health professional to report a SE due to legal effects.
Describe the strategies used to overcome the barriers (If needed)
In the Italian Health care System, according to the regions, there is a Clinical Risk Manager in every hospital .
Also there are training courses about patient safety and risk management avilble at national, regional an local level.
Other information
Other information about the GOP that you would like to add (Link or attached document)
This system gives the possibility to know the areas needing more attention, it springs up the real problems, and the need of elaborate and disseminate Recommendations, Guide Lines, policy requirements and Best Practices.