2008/09 Serious and Sentinel Events

30/11/2009 | 2008/09 Serious and Sentinel Events

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

The events are from the year 1 July 2008 to 30 June 2009.

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.

MidCentral Health’s Medical Director Dr Kenneth Clark, Director of Nursing Sue Wood, Director of Patient Safety and Clinical Effectiveness Muriel Hanratty, and Chief executive Murray Georgel lead our sentinel event process.
Since 1 January 2009 MidCentral District Health Board, as with the other 20 DHBs, began a new form of reporting serious and sentinel events through the New Zealand Incident Management System (NZIMS) project. It is expected to take over a year to fully implement due to staff training requirements.

In order to achieve a nationally consistent approach to the management of healthcare incidents across the health and disability sector all DHBs have changed their approach to adverse events through the NZIMS project.

Under the NZIMS all DHBs have adopted the Severity Assessment Code (SAC) rating for defining, reporting and acting upon health care incidents (see information attached). Under the SAC rating system SAC1 will signify the most serious events through to SAC4 for least serious.

In the 2008-09 year under review MidCentral Health had eight serious and sentinel events – two were classified as SAC1, and six SAC2. There were no SAC3, or SAC4 events investigated. Two incidents resulted in deaths.

The eight events were:

Four clinical management problems (three involving delayed or inadequate treatment), and one a misdiagnosis. Two people subsequently died.
Three were falls (all resulting in fractures).
One incident was classified as “other” resulting in a patient receiving a fracture while being restrained.

In releasing information about each of the eight cases, every effort has been made not to identify the patients involved, or the staff who were involved in each patient’s care, to respect privacy issues. Despite this best endeavour patients and/or their families may believe they identify with one of the cases highlighted. hose patients (or their families) have been contacted and advised of the need to release their information as part of this national process.

MidCentral DHB strongly supports the national DHB initiative led by the Quality Improvement Committee to enhance reporting about sentinel and other events.
More information regarding sentinel event reporting in New Zealand can be accessed from the Quality Improvement Committee website.

Murray Georgel
CEO
MidCentral District Health Board

Dr Kenneth Clark
Medical Director
MidCentral Health