Thursday 22 May 2025 | 15:00-16:00

Format: In the round

Stream: Safety

Content filters: Recommended for those new to quality improvement

Sentinel events have an enormous impact on patients, relatives and also professionals. Dealing with the victims and conducting a good and respectful investigation can be challenging. Current views on patient safety warrants important developments in perspectives such as Safety-II (S-II) and Just Culture (JC). The delegates will be guided towards the new policies to improve sentinel event investigations based on human factors analyses. Special attention will be given to respectful inquiring professionals and better communication with the patients and relatives.

The presenters have extensive experience with investigations based on human factors analysis and applying Just Culture principles for the professionals. Patients or relatives will comment their experience with the aftermath of their experienced sentinel event.

Delegates will be challenged step by step of the aspects of before mentioned principles. Als the Dutch Health Care and Youth Inspectorate will share their experience with the new way of investigating sentinel events.

After this session, participants will be able to:

• Understand the benefits of human factors analysis of sentinel events


• Recognise and know the needs of patients and relatives involved in sentinel events


• Recognise and know what professionals need after a sentinel event

Anja Brunsveld-Reinders Leiden University Medical Center; Netherlands

Ian Leistikow Dutch Health and Youth Care Inspectorate and Erasmus School of Health Policy & Management; Netherlands

Jaap Hamming Leiden University Medical Center; Netherlands