Between saying and doing there is the health organization. How the health organization changes following the occurrence of sentinel events: a qualitative study within the South Tyrolean Health Organization

a qualitative study within the South Tyrolean Health Organization

  • Horand Meier
  • Luana Casanova Stua Health Authority - Autonomous Province of South Tyrol
Keywords: Sentinel events, Organizational improvement, Organizational change, Organizational strategies, Leadership, Management, Analysis meeting, Exemplified tools, Root Cause Analysis, Health organization


Background: The clinical risk in Italy is oriented to detect the technical aspects of risk management: how many reports of undesirable events are received in the company, what kind of events are most reported, the outcomes for patients and the organizational improvement measures identified for risk reduction. Aim of the authors is to analyze the process of management of sentinel events within the South Tyrolean Health Authority, to understand what happens in the health organization after the identification of the improvement measures, what kind of factors and strategies hinder organizational change or make its implementation effective.

Methods: 18 semi-structured interviews were conducted: 3 to head physicians, 5 to nursing coordinators, 4 to quality referents, 3 nursing managers, 3 to clinical directors. The following dimensions were investigated: the attitude towards risk, the communication of errors, the process of managing sentinel events, the perception of analysis meetings, the factors that hinder or favor the implementation of corrective actions, strengths and weaknesses of the risk management system.

Results: Timeliness and simplicity of the analysis tool are considered relevant for taking charge of the emotional aspects and for the greater involvement of collaborators in the process of managing sentinel events. The use of a simplified tool is considered functional, intuitive even for proactive risk analyzes. The authority of the leadership is considered relevant for the purposes of organizational change. Organizational change occurs if the staff is motivated and perceives the improvement measures as useful.

Conclusions: Directing and leading people towards common goals does not only require that they are officially shared at different levels: social actors have primarily individual needs that they try to satisfy. To combat errors in clinical practice it is crucial to take the new perspective of the social nature of the decision-making process and of the organizational change.