Investigating Sentinel Event Incidents as a Key Performance Indicator, Al-Ahsa Health Cluster, Saudi Arabia

Abstract Background: Sentinel events (SEs) are preventable incidents causing death, permanent harm or severe temporary harm, contributing to significant burdens worldwide. In Saudi Arabia, reducing SEs aligns with Vision 2030 initiatives, including the Saudi Patient Safety Center. Limited regional data on SE prevalence highlight the need for further investigation. Objectives: To analyse the incidence, types and contributing factors of SEs in ten healthcare facilities over 6 months in 2023, offering insights for improving patient safety. Design: A retrospective, observational study of SEs reported by healthcare facilities. Setting: Ten hospitals in Saudi Arabia provide general and specialised healthcare services. Materials and Methods: SE data from January to June 2023 were extracted from the Ministry of Health’s Sentinel Event Platform. Variables included event types, outcomes and contributing factors. Descriptive statistics and visualisations were used. Results: Twelve SEs were reported across ten hospitals. Most cases involved unexpected adult patient deaths, maternal deaths and falls causing severe harm. Other events included unexpected deaths of a paediatric and neonate patient, severe permanent harm from medication errors and severe temporary harm related to a medical device. The primary contributing factors were work environment, task and patient-related factors. Conclusions: The findings highlight key areas for improvement in patient safety. Future research should extend study duration and incorporate qualitative methodologies to deepen the understanding. Limitations: The 6-month study period and potential underreporting may limit generalisability. Longer studies and qualitative data are recommended.