Sentinel Events

20/02/2008 | Sentinel Events

MidCentral Health has released summary details of four sentinel events as part of a national release of this information.

The events are from the year 1 July 2006 to 30 June 2007.

Sentinel events are defined as those that have a significant effect on the patient, result in permanent disability or death, and result from the management of the patient’s illness, disease or condition.

These four events involved a wrong-site surgery; a patient’s unexpected death; an unexpected death of a fetus during labour; and a self-harm injury. Any recommendations from these sentinel event processes have been acted on, or are in the process of being completed. A copy of the summary details is attached.

MidCentral Health’s Medical Director Dr Kenneth Clark, Director of Nursing Sue Wood, and General Manager Lareen Cooper lead our sentinel event process. They said “We encourage open reporting of all incidents, including sentinel events. It is of paramount importance that when a sentinel event or other incident occurs, our systems and processes are formally reviewed and improvements made.”

The patients and/or their families involved in the four sentinel events of 2006/07 have been notified of the public release of information. All information has been anonymised to protect their personal privacy.

“We acknowledge the impact that these events have had on the lives of those patients and their families, as well as the staff involved, and regret any distress that these events have caused” said Lareen Cooper.

MidCentral DHB strongly supports the national initiative by DHBs to enhance reporting about sentinel and other events and is committed to full participation in the development of new national systems and standards.
More information regarding sentinel event reporting in New Zealand can be accessed from the Quality Improvement Committee’s website, www.qic.health.govt.nz.

For any further comments, please contact Medical Director Dr Kenneth Clark via the Communications Unit, on telephone (06) 350-8945.