Paving the Way: Lessons Learned in Sentinel Event Reviews   [open pdf - 528KB]

"When bad things happen in a complex system, the cause is rarely a single act, event or slip-up. More often, bad outcomes are 'sentinel events.' A sentinel event is a negative outcome that: [1] Signals underlying weaknesses in a system or process. [2] Is likely the result of compound errors. [3] May, if properly understood, provide important keys to strengthening the system and preventing similar adverse outcomes in the future. Sentinel event reviews (SER) were initially developed as a process for better understanding the causes of industrial accidents. They were later adapted in aviation and in medical environments. The SER process brings all stakeholders to the table on a regular basis to discuss, in a nonblaming way, why a negative outcome or event happened. The overarching goal of SER is to mobilize a routine, culture-changing practice that can lead to increased system reliability and, hence, greater public confidence in a system's legitimacy."