Inadvertent adolescent pregnancy: a sentinel analysis

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The sentinel event identified was undiagnosed adolescent pregnancy before the indication of potentially harmful treatments or diagnostic methods. The team performed a root-cause analysis where the following causes were identifed: a) Paediatrician bias: not thinking about adolescent sexual behaviour, incomplete questionnaires, insufficient training in adolescent interviews. b) Social factors: legal issues, ambiguous contraceptive recommendations. c) Hospital factors: lack of guidelines for counselling adolescents. d) Host risk factors: cultural barriers, lack of confidence. Regardless of any previous negative pregnancy test results, any time that a new potentially harmful procedure is indicated in a fertile female patient, a test of pregnancy diagnosed might be performed.