National policies for risk management in Italy

The Ministry of Health in Italy considers risk management (RM) to be one of the specific objectives to be developed by its national policies, as suggested by the European Union recommendations and by several international organizations, such as the World Health Organization (WHO), the Council of Europe, and the Organization for Economic Cooperation and Development. The National Health Plan stated the need to guarantee and monitor safety of health care and biomedical technology, with the development of a standardized computerized method to collect and analyze data on adverse events and with specific actions for education and training of all stakeholders, which is to be conducted at different levels of the health system governance, national, regional, and local. Over a 4-year period, the National Observatory for the Monitoring of Sentinel Events has collected data on 385 sentinel events, with a mortality rate of 54.8%. Compared with earlier reports, we have observed a reduction from 41% to 17% of sentinel events classified in the "nonspecified sentinel event" and an increase from 20% to 40% of cases in which an action plan has been developed. A manual for root cause analysis has been released with the aim of offering health operators an instrument to analyze the occurrence of an adverse event. Ten recommendations and a manual for safety in the operating room, which includes a checklist for safe surgery adapted on the basis of WHO suggestions, have been published. To date, eight guidelines for safety have been released to improve stakeholders' accountability. The Ministry of Health has also elaborated a program of specific actions to be developed over the next 2 years in several areas of RM. These initiatives confirm the strategic role of policies for RM in our country, allowing for a dynamic and proactive process, ensuring continuity of action and promoting a deep understanding of patient safety issues.