The aim of this study was to establish how performance variability contributes to perioperative sentinel events, by examining how often performance variability is included in sentinel event analysis reports and forms the basis for suggested improvement measures. Previously, Dutch hospitals have indicated that the teams performing sentinel event analyses do not usually have specific training or knowledge on performance variability, although the literature shows that this could contribute to addressing such variability adequately within a sentinel event analysis 4. Performance variability also has a profound impact on quality of care, but the integration of this as a factor in healthcare quality management remains scant 12, 13. Reduction in performance variability is an important goal of quality management in industrial production and laboratory measurement 10, 11. Performance variability is the positive or negative variation in behaviour and performance caused by environmental, organizational, and work-related factors, as well as human and individual characteristics 8, 9. One such factor is performance variability 4. The capacity to develop effective improvement measures is impaired when sentinel event analyses overlook relevant contributing factors 7. Research suggests this might be due to the quality of the improvement measures 4, 6. Although the quality of sentinel event analysis has increased, similar events keep recurring 4, 5.
Healthcare organizations in many countries are mandated to report sentinel events to national reporting systems, analyse them to determine root causes, and develop improvement measures to prevent recurrence 3, 4. Sentinel events are unintended events causing death or serious harm to patients, and these remain widespread in healthcare across the globe 1, 2.
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