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Serious and Sentinel Events Report
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The Wanganui District Health Board has welcomed today's annual report of serious and sentinel events released by the Health Quality & Safety Commission New Zealand.
A serious or sentinel event has, or has the potential to result in, serious lasting disability or death, not related to the natural course of the patient’s illness or underlying condition.
Whanganui District Health Board Chief Executive Julie Patterson said the district health board had an open disclosure policy and actively encouraged staff to report any adverse event, or event that had the potential to cause harm.
“These events are traumatic for the patients involved and their families. It is also distressing for clinical staff,” Mrs Patterson said.
“We consider it very important to review and learn from serious and sentinel events to reduce the likelihood of this kind of avoidable harm in the future. Priority has been given to achieving a culture where staff report incidents and near misses, because they know how important it is to learn from these incidents and how essential open disclosure is for patients, families and the community at large.
“All our staff are highly committed to patient safety and take a great interest in this report.”
The Wanganui DHB had nine serious and sentinel events in the year from 1 July 2009 to 1 July 2010:
Professor Merry said in the 2009/2010 year, district health boards treated and discharged close to one million people.
“Of these, 374 people were involved in a serious or sentinel event that was actually or potentially preventable. Of those people, 127 died during admission or shortly afterwards, though not necessarily as a result of the event. Half of these deaths occurred through suicide.”
The three most commonly reported serious and sentinel events for 2009/2010 nationwide were falls (34 percent), clinical management problems (33 percent) and suicides (17 percent). In the 2008/2009 year there were 308 reported events and 92 deaths, with falls, clinical management problems and suicides also the biggest categories.
Professor Merry said the increase in reported events was anticipated and it illustrated improved reporting processes in hospitals and a greater awareness of health and safety processes.
“International experience with event reporting shows that the process of increasing awareness often results in a rise in the number of events reported.
“It’s encouraging that many DHBs and private hospitals are introducing specific programmes and changes to make real improvements in patient safety.”
National changes include:
A serious or sentinel event has, or has the potential to result in, serious lasting disability or death, not related to the natural course of the patient’s illness or underlying condition.
Whanganui District Health Board Chief Executive Julie Patterson said the district health board had an open disclosure policy and actively encouraged staff to report any adverse event, or event that had the potential to cause harm.
“These events are traumatic for the patients involved and their families. It is also distressing for clinical staff,” Mrs Patterson said.
“We consider it very important to review and learn from serious and sentinel events to reduce the likelihood of this kind of avoidable harm in the future. Priority has been given to achieving a culture where staff report incidents and near misses, because they know how important it is to learn from these incidents and how essential open disclosure is for patients, families and the community at large.
“All our staff are highly committed to patient safety and take a great interest in this report.”
The Wanganui DHB had nine serious and sentinel events in the year from 1 July 2009 to 1 July 2010:
- 4 deaths by suicide of a community mental health patient known to the service within 7 days of their deaths.
- 2 deaths resulting from falls
- 1 incorrect referral process for surgical assessment
- 1 medication error
- 1 death as a result of infection following a plasma exchange
Professor Merry said in the 2009/2010 year, district health boards treated and discharged close to one million people.
“Of these, 374 people were involved in a serious or sentinel event that was actually or potentially preventable. Of those people, 127 died during admission or shortly afterwards, though not necessarily as a result of the event. Half of these deaths occurred through suicide.”
The three most commonly reported serious and sentinel events for 2009/2010 nationwide were falls (34 percent), clinical management problems (33 percent) and suicides (17 percent). In the 2008/2009 year there were 308 reported events and 92 deaths, with falls, clinical management problems and suicides also the biggest categories.
Professor Merry said the increase in reported events was anticipated and it illustrated improved reporting processes in hospitals and a greater awareness of health and safety processes.
“International experience with event reporting shows that the process of increasing awareness often results in a rise in the number of events reported.
“It’s encouraging that many DHBs and private hospitals are introducing specific programmes and changes to make real improvements in patient safety.”
National changes include:
- most DHBs, and a number of private hospitals, have adopted the World Health Organization’s Safe Surgery Checklist
- many DHBs have instituted or improved comprehensive falls prevention programmes
- booking and referral processes have been improved
- a standardised medication chart is about to be introduced throughout New Zealand to reduce medication errors related to adult inpatients
- a standardised process to reconcile medicines and reduce medication errors at the point of handover of patient care is planned for all DHBs and has already been adopted by some, and by some private hospitals.
The Whanganui District Health Board has adopted all five national changes.
Professor Merry said New Zealand has an excellent health system by international standards and the vast majority of patients are treated safely and effectively. However, for a small number of people, preventable incidents occur.
The Ministry of Health releases serious and sentinel health events from every district health board across the country in November of each year.
For more information visit www.hqsc.govt.nz
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