Barriers to Sentinel Events Reporting in Tertiary Hospital at Dammam, Saudi Arabia

Rania Ali


The objective of this study was to find out the barriers of sentinel events reporting at tertiary hospital and then formulate recommendations to ameliorate based the findings of this study. The study was carried out in 2015 and conducted as two parts; the first part is a retrospective data, review of Occurrence Variance Reports forms according to the reporter. The second part was through self-administered questionnaires, which was randomly distributed to the hospital staff. A total of 120 completed questionnaires out of 135 were received.  In this study, we found that the commonest reasons that prevent the hospital staff from reporting the sentinel events are poor communication of policy and procedure of sentinel events reporting, lack of motivation among the staff to report sentinel events in 28 % and 26 % respectively. Staff fear of punitive actions from the hospital administration was rated as the first and second priority reason in preventing employee reporting sentinel events in about half of the cases. No feedback from reporting sentinel events was the reason for underreporting in about one fifth. Sentinel events definition was not clear and sentinel cases reporting form was not available in 14 % and 15 % respectively. This study highlights the common factors that may contribute to under-reporting of sentinel events in tertiary hospital. The findings may be useful in formulating beneficial strategies to improve reporting which will have great value on quality of care and patient safety.


OVR, Occurrence, Near miss, Sentinel Events, Under-reporting, Barriers

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