• Andrej Robida Oddelek za kakovost Ministrstvo za zdravje Štefanova 5 1000 Ljubljana
Keywords: medical errors, organizational culture, root causes, adverse events, near misses


Background. The Objective of the article is a two year statistics on sentinel events in hospitals. Results of a survey on sentinel events and the attitude of hospital leaders and staff are also included. Some recommendations regarding patient safety and the handling of sentinel events are given.

Methods. In March 2002 the Ministry of Health introduce a voluntary reporting system on sentinel events in Slovenian hospitals. Sentinel events were analyzed according to the place the event, its content, and root causes. To show results of the first year, a conference for hospital directors and medical directors was organized. A survey was conducted among the participants with the purpose of gathering information about their view on sentinel events. One hundred questionnaires were distributed.

Results. Sentinel events. There were 14 reports of sentinel events in the first year and 7 in the second. In 4 cases reports were received only after written reminders were sent to the responsible persons, in one case no reports were obtained. There were 14 deaths, 5 of these were in-hospital suicides, 6 were due to an adverse event, 3 were unexplained. Events not leading to death were a suicide attempt, a wrong side surgery, a paraplegia after spinal anaesthesia, a fall with a femoral neck fracture, a damage of the spleen in the event of pleural space drainage, inadvertent embolization with absolute alcohol into a femoral artery and a physical attack on a physician by a patient. Analysis of root causes of sentinel events showed that in most cases processes were inadequate.

Survey. One quarter of those surveyed did not know about the sentinel events reporting system. 16% were having actual problems when reporting events and 47% beleived that there was an attempt to blame individuals. Obstacles in reporting events openly were fear of consequences, moral shame, fear of public disclosure of names of participants in the event and exposure in mass media. The majority of the surveyed persons agreed to disclosure of the event to a patient but this was the case in less than half of the occasions.

Conclusions. The small number of reports of sentinel events, late or incomplete reporting of conducted analyses of root causes and plans for future prevention of these events and survey data showed the state of culture in the majority of hospitals. Fear of reporting and therefore, hiding of errors or ascribing errors to the »usual« complications of a disease or procedures, the reaction of leadership to quickly find a culprit for the event, disregarding a serious approach to analyze the event and taking measures for their future prevention leads to the culture of silence. Root cause analysis of the events showed that the reason frequently lies in systems and processes and not in individuals. Health care will never be without risks for patients. However, with an open approach without the blaming and shaming of individuals, implementation of reporting the events in hospitals and other health care facilities with clear goals of patient safety, standardization of equipment, materials, and processes and education on patient safety many sentinel events and medical errors could and should be prevented.


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Joint Commission for Accreditation of Healthcare Organization. Root cause analysis in health care. Oakbrook Teracce: Joint Commission for Accreditation of Healthcare Organization, 2000.

Prager LO. Learn from mistakes. Am Med News 1999; 42: 9–10.

Institute of Medicine. To err is human. Building a safer health system. Washington: National Academy Press, 2000: 1–4.

Ministrstvo za zdravje Republike Slovenije. Zdravstvena napaka. http://

Van der Schaff. Near miss reporting in the chemical process industry. Eindhoven: Technical University Eindhoven, 1992.

Korošec D. Medicinsko kazensko pravo. Ljubljana: Cankarjeva založba, 2004: 95–105.

Robida A. Opozorilni nevarni dogodki. Isis 2002; 5: 39–47.

Dew JR. In search of the root cause. Qual Prog 1991; 24: 97–102.

Cooper JB. Is voluntary reporting of critical events effective for quality assurance? Anesthesiology 1996; 85: 961–4.

Scherkenbach W. The Deming root of quality and productivity: Road maps and road blocks. Washington: CEE Press Books, 1991.

Berwick DM, James B, Coye MJ. Connection between quality measurement and improvement. Med Care 2003; 41 (suppl 1): I30–8.

Kersnik J. Zdravstvene napake. 19. učne delavnice za zdravnike družinske medicine. Ljubljana: Združenje zdravnikov družinske medicine SZD, 2002.

Blumenthal D. Making medical errors into »medical treasures«. JAMA 1994; 272: 1867–8.

The Australian Council for Safety and Quality in Health Care. Safety through action. Canberra: Commenwealth of Australia, 2002.

Crane M. How good doctors can avoid bad errors. Med Econ 1997; 16: 16– 21.

Stoop J. Independent accident investigation: a modern safety tool. J Hazard Mater 2004; 26; 111: 39–44.

How to Cite
Robida A. SENTINEL EVENTS. ZdravVestn [Internet]. 1 [cited 17Sep.2019];73(9). Available from:
Quality and safety