摘要：In 2005, the Ministry of Welfare started a
protocol for reporting sentinel events, in order
to provide monitoring of such events at the national level in a way that makes the data available to
others. The main objectives of the monitoring system include the collection of information of sentinel
events which occurred in NHS structures. The analysis focused on systems, processes and determining
factors contributing to the occurrence of these events, compilation and implementation of recommendations
addressed to all the NHS hospitals to minimize the risk of occurrence, and feedback to local
health services and Regions. This study describes sentinel events reported to the Ministry of Welfare
in the first eighteen months of activity, during which it received 123 reports of sentinel events, suicide
being the most reported event. The analysis of the causes and contributing factors has highlighted the
lack of application, and sometimes the total absence of appropriate procedures and guidelines which
would allow the identification of the possible actions to be taken to counteract the recurrence of these
serious events in the interest of public health. In particular, it highlighted the need to disseminate and
implement specific recommendations to prevent errors, promote training on clinical risk and improve
communication among operators and between operators and patients. Given the importance of suicide
in public health policies and the need for preventive activity on this issue, recommendations for
the prevention of suicide in hospitals have already been drafted.
