Suicide in the national protocol for monitoring sentinel events

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.