Performance variability in perioperative sentinel events: report on a nationwide data set.

This study aimed to evaluate how performance variability contributes to perioperative sentinel events occurring within the Dutch healthcare system. Although performance variability was identified as a contributing factor in almost all analysis reports, it remains unrecognized by the sentinel event analysis team. Strengthening the integration of performance variability in sentinel event analyses could improve the analyses performed, and lead to more effective improvement measures specifically aimed at optimizing human performance within the healthcare system.