E4: Improving the quality of recommendations in sentinel event analysis


Wednesday 17 May | 13:15-14:30


Format: Presentation
Stream: Safety
Content filters: n/a


The process of learning the lessons of an sentinel event (SE) has several distinct stages: 1) reporting the SE, 2) analysing the SE, 3) formulating recommendations, 4) implementing recommendations and finally, 5) evaluating the effect of implemented recommendations. Completing the learning process and optimising the different stages will lead to quality improvement and a decrease in the number of recurrent SEs. We specifically focus on the third stage of the learning process and have developed a strategy to determine if a recommendation can be expected to be effective.


After this session, participants will be able to:



  • Have a conceptual idea and approach to formulate worthy recommendations

  • Select and formulate high-quality recommendations

  • Grade high-quality recommendations based on objective features to help formulate effective and sustainable recommendations


Kelly Bos, ​​Amsterdam UMC, The Netherlands


Maarten van der Laan, University Medical Centre Groningen, The Netherlands