Criteria for recommendations after perioperative sentinel events

Abstract

BackgroundThe recurrence of sentinel events (SEs) is a persistent problem worldwide, despite repeated analyses and recommendations formulated to prevent recurrence. Research suggests this is partly attributable to the quality of the recommendations, and determining if a recommendation will be effective is not yet covered by an adequate guideline. Our objectives were to (1) develop and validate criteria for high-quality recommendations, and (2) evaluate recommendations using the criteria developed.Methods(1) Criteria were developed by experts using the bowtie method. Medical doctors then determined if the recommendations of Dutch in-hospital SE analysis reports met the criteria, after which interobserver variability was tested. (2) Researchers determined which recommendations of Dutch perioperative SE analysis reports produced from 2017 to 2018 met the criteria.ResultsThe criteria were: (1) a recommendation needs to be well defined and clear, (2) it needs to specifically describe the intended changes, and (3) it needs to describe how it will reduce the risk or limit the consequences of a similar SE. Validation of criteria showed substantial interobserver agreement. The SE analysis reports (n=115) contained 442 recommendations, of which 64% failed to meet all criteria, and 28% of reports did not contain a single recommendation that met the criteria.ConclusionWe developed and validated criteria for high-quality recommendations. The majority of recommendations did not meet our criteria. It was disconcerting to find that over a quarter of the investigations did not produce a single recommendation that met the criteria, not even in SEs with a fatal outcome. Healthcare providers have an obligation to prevent SEs, and certainly their recurrence. We anticipate that using these criteria to determine the potential of recommendations will aid in this endeavour.

Using the Generic Analysis Method to Analyze Sentinel Event Reports Across Hospitals: A Retrospective Cross-Sectional Study

“…Literature suggests SE investigators typically avoid these types of interventions. 33 , 36 Because the aggregated cross-hospital GAM analysis recommendations are based on multiple SEs from various hospitals, they may provide more relevance and urgency than case-specific recommendations. In turn, this could help to mobilize the appropriate resources to implement and follow-up on recommendations.…”

“…18,35 These types of recommendations are considered to be weak. Bos et al 36 confirmed this finding regarding generally weak recommendations, as they concluded that the majority of recommendations in 115 Dutch SE reports did not meet quality criteria and thus may have limited effect in improving patient safety. On the other hand, aggregate cross-hospital GAM analysis helped to formulate more system-oriented recommendations aimed at solving recurring issues across events and organizations.…”

“…Such system-level recommendations, however, may require substantial (financial) resources. Literature suggests SE investigators typically avoid these types of interventions 33,36 . Because the aggregated cross-hospital GAM analysis recommendations are based on multiple SEs from various hospitals, they may provide more relevance and urgency than case-specific recommendations.…”