Classify a clinical event using a severity assessment code and decide whether it warrants a full sentinel event review.
Healthcare & Pharmaceutical Management
Just Culture and Sentinel Event Review in Patient Safety Programmes
Build a just culture that separates human error from reckless conduct and lead sentinel event reviews that turn findings into lasting clinical safety improvements.
🗓️Duration5 training days
📚Content4 modules · 8 sessions
🎓On completionAccredited attendance certificate
About the programme
Course Overview
When a serious clinical incident occurs, the response of the organisation determines whether staff report the next near miss or hide it. This course addresses the practical challenge facing patient safety leaders: how to hold people accountable without punishing honest mistakes, and how to run a sentinel event review that produces findings the organisation actually acts on. Participants work through the algorithm used to separate human error, at-risk behaviour and reckless conduct, examine how severity assessment codes triage which events trigger a full review, and practise structured root cause analysis using timeline reconstruction and contributing factor mapping. The course also covers how to support staff involved in an adverse event as second victims, and how to design corrective actions that use human factors engineering rather than retraining alone. Case-based exercises drawn from operating theatres, medication administration and diagnostic pathways let participants chair a mock review panel, draft a review report and present recommendations to a safety committee. The result is a leader who can build psychological safety for reporting while still applying proportionate accountability when it is warranted.
Expected Learning Outcomes
Apply a just culture algorithm to distinguish human error, at-risk behaviour and reckless conduct in a specific case.
Facilitate a root cause analysis session using timeline reconstruction and contributing factor mapping techniques.
Draft a sentinel event review report that links contributing factors to specific, measurable corrective actions.
Design corrective actions that apply human factors engineering principles instead of relying on staff retraining alone.
Establish a second victim support pathway for clinicians involved in a serious adverse event.
Present review findings and recommendations to a safety committee in a format that drives accountable follow-up.
Who Should Attend
Patient safety officers and quality managers leading incident review processes
Clinical directors and heads of department responsible for departmental safety culture
Risk managers who chair or contribute to root cause analysis panels
Nurse and physician leaders handling staff support after adverse events
Accreditation and compliance staff preparing safety programmes for external review
Hospital executives sponsoring organisational just culture initiatives
Course Modules
Select any module to see its sessions and points.
01Foundations of Just Culture in Clinical Settings
2 sessions · 8 points
Session 1Distinguishing Human Error, At-Risk Behaviour and Recklessness
- Apply a structured decision algorithm to sort a reported event into human error, at-risk behaviour or reckless conduct.
- Compare disciplinary approaches appropriate to each category, from system redesign to formal sanction.
- Identify how blame-oriented responses suppress future reporting and distort incident data over time.
- Analyse a documented case where miscategorisation of an event damaged staff trust in the reporting system.
Session 2Building Psychological Safety and Trust for Reporting
- Design leadership behaviours that visibly separate learning conversations from disciplinary ones after an event.
- Draft a fair and consistent response protocol that staff can predict before they choose to report.
- Evaluate survey and focus-group methods for measuring psychological safety within a clinical unit.
- Plan a communication sequence that explains a just culture policy change to sceptical frontline staff.
02Sentinel Event Classification and Reporting Systems
2 sessions · 8 points
Session 1Severity Assessment and the SAC/Harm Matrix
- Score an incident against a severity assessment code matrix combining harm outcome and likelihood of recurrence.
- Determine the review pathway and reporting timeline triggered by each severity tier under local policy.
- Distinguish a sentinel event from a serious reportable event and a near miss for internal escalation purposes.
- Justify an escalation decision to hospital leadership using the matrix's documented scoring rationale.
Session 2Voluntary Reporting Systems and Near-Miss Capture
- Configure a voluntary incident reporting system to lower barriers to entry for busy clinical staff.
- Design feedback loops that show reporters how their submissions changed practice, sustaining participation.
- Audit reporting rates by unit and shift to identify pockets of under-reporting requiring targeted follow-up.
- Integrate near-miss data with sentinel event trends to surface systemic risks before serious harm occurs.
03Conducting the Sentinel Event Review
2 sessions · 8 points
Session 1Root Cause Analysis and the London Protocol
- Assemble a multidisciplinary review team with the independence and expertise a sentinel event requires.
- Apply the London Protocol framework to separate active failures from latent organisational conditions.
- Use the five-whys and fishbone techniques to trace a clinical error back to systemic contributing factors.
- Manage interview technique with involved staff to gather accurate accounts without triggering defensiveness.
Session 2Timeline Reconstruction and Contributing Factor Mapping
- Construct a detailed event timeline from clinical records, device logs and staff statements.
- Map contributing factors against categories such as staffing, equipment, communication and workload.
- Identify decision points in the timeline where a different action would plausibly have prevented harm.
- Cross-check timeline findings against similar past events to detect recurring systemic weaknesses.
04Translating Findings into Sustained Improvement
2 sessions · 8 points
Session 1Corrective Action Design and Human Factors Engineering
- Rank candidate corrective actions using a hierarchy that favours forcing functions over reminders and training.
- Redesign a clinical workflow, form or device interface to remove the opportunity for the identified error.
- Assign action owners and realistic deadlines within a tracked corrective action plan.
- Define measurable indicators that will confirm whether a corrective action actually reduced recurrence.
Session 2Second Victim Support and Organisational Learning
- Establish a peer support pathway for clinicians experiencing distress after involvement in a serious event.
- Distinguish confidential emotional support processes from the formal investigation to protect staff wellbeing.
- Share de-identified lessons from a review across the organisation without exposing individuals to blame.
- Track long-term trends in sentinel event types to demonstrate the safety programme's cumulative impact.
What the participant receives
4 course modules
A structured syllabus
8 training sessions
across 5 days
32 detailed points
Applied, detailed content
Accredited attendance certificate
On completing the programme
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