Improved quality of recommendations after sentinel event analysis with recommendation improvement matrix training: a before-and-after study at an international patient safety conference.

objectiveTo evaluate the effectiveness of the recommendation improvement matrix (RIM) methodology for improving the quality of recommendations resulting from sentinel event analysis, where we hypothesise that the use of the RIM methodology leads to better quality recommendations.

designA before-and-after analysis of the quality of the formulated recommendations after sentinel event analysis.

settingThe study was carried out during the 2023 Saudi Patient Safety Centre International Patient Safety Conference.

participants36 conference participants, including nurses, medical doctors, pharmacists, dentists, general practitioners and quality officers.

interventionsRIM methodology training during a structured 3-hour workshop.

main outcome measuresThe primary outcome was the proportion of recommendations that using the χ

resultsPrior to training, 49 recommendations were generated, of which 63.3% met the filter criteria. Post-training, the proportion of recommendations passing the filter increased significantly to 83% (p=0.00543). Adjustments to recommendations primarily improved alignment with the filter criteria, though limited improvements were observed in matrix categorisation. Participants rated the methodology's feasibility and usability highly, with average scores of 4.39/5 and 4.43/5, respectively. However, 46% expressed a need for additional training, particularly on the matrix application.

conclusionsThe RIM methodology significantly improves the quality of recommendations following sentinel event analyses. To enhance its impact, further training focusing on matrix application is necessary. Incorporating the methodology into healthcare education and professional development could strengthen patient safety practices.