“Sentinel events” are those adverse events of particular gravity, which cause death or serious damage to the patient and which determine a loss of confidence of citizens in the Health Service.
The surveillance of sentinel events, already implemented in other countries, constitutes an important public health action, representing an indispensable tool for the prevention of such events and for the promotion of patient safety.
For this reason, the Ministry of Health has developed, with the technical support of experts, a protocol for monitoring sentinel events, with the aim of providing the Regions and Health Authorities with a unique way of monitoring and managing such events on the national territory. , a guarantee of the essential levels of assistance.
The reporting of a sentinel event must be made to the Information System for Monitoring Errors in Healthcare (SIMES) only through the dedicated IT platform.
- Sentinel Event List
- Wrong patient procedure
- Surgical procedure in the wrong part of the body (side, organ or part)
- Wrong procedure on correct patient
- Tool or other material left inside the surgical site that requires later surgery or further procedure
- Transfusion reaction resulting from AB0 incompatibility
- Death, coma or severe injury resulting from errors in drug therapy
- Maternal death or serious illness related to labor and / or delivery
- Permanent death or disability in a healthy infant weighing> 2500 grams not related to congenital disease
- Death or serious injury due to a fall of a patient
- Suicide or attempted suicide of patient in hospital
- Violence on patient
- Acts of violence against the operator
- Death or serious damage resulting from a malfunction of the transport system (in-hospital, out-of-hospital)
- Death or serious damage resulting from incorrect attribution of the triage code in the 118 Operations Center and / or inside the Emergency Department
- Unexpected death or serious injury following surgery
- Any other adverse event that causes death or serious harm to the patient
- Consult the full text of the protocol for the monitoring of sentinel events:
The Information System for Monitoring Errors in Healthcare (SIMES)
The State-Regions Conference has reached an agreement on the promotion of monitoring of sentinel events, through systematic transmission to the New Health Information System (NSIS), through a specific flow, delegating to the Ministry of Health the activation of the National Observatory of sentinel events to which the related data flow. The agreement also provides that the National Agency for Regional Health Services performs the functions of the National Observatory for reporting claims and insurance policies.
The Information System for Monitoring Errors in Healthcare (SIMES) aims to collect information relating to sentinel events and the reporting of claims throughout the national territory, risk assessment and complete monitoring of adverse events. This process represents a very important part, preliminary to any continuous improvement action in terms of clinical risk.
The Ministerial Decree of 11 December 2009, developed jointly by the General Management of the information system and the General Management of health planning, of the essential levels of assistance and of the ethical principles of the system and shared within the control room of the New Health Information System and the Committee technician of the Regions and Autonomous Provinces of Trento and Bolzano for patient safety. The decree regulates the representation of information relating to sentinel events and the reporting of claims and describes the methods of transmission of such data from the Regions and the Autonomous Province to the New Health Information System.