Serious & Sentinel Events
Reporting serious and sentinel events nationally signifies an important step on the road to improving health outcomes for New Zealanders. The key is to improve safety by encouraging open and transparent reporting of incidents when something goes wrong.
The intention of the report is to support DHBs' continuous quality improvement focusing on shared learning to move towards improving systems and minimising the possibility of future incidents.
Background to national annual reporting of Serious and Sentinel events
2008/09 information, reports and links
2007/08 information, reports and links
Background to national annual reporting of Serious and Sentinel events
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.
In 2007 the Health and Disability Commissioner issued the sector a challenge to come up with a system to report and measure these events and provide comparative statistics as part of the process of making patient care safer.
In order to achieve a nationally consistent approach to the management of healthcare incidents across the health and disability sector all DHBs are working toward changing their approach to adverse events through the NZIMS project (refer national Quality Improvement Committee (QIC) projects) .
Under the NZIMS all DHBs will adopt 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.
From 1 January 2009 MidCentral District Health Board began a new form of reporting serious and sentinel events through the New Zealand Incident Management System (NZIMS) project.
2008/09 information, reports and links
For the reporting year 2008/09 District Health Boards reported that 308 people treated in New Zealand hospitals were involved in potentially preventable serious or sentinel events that were actually or potentially preventable.
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. 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.
Further information is available from the following links:
2007/08 information, reports and links
For the reporting year 2007/08 District Health Boards nationally reported 258 people treated in their hospitals were involved in a serious or sentinel adverse clinical event that was actually or potentially preventable.
Of this total, 76 died during the admission or shortly afterwards, though not necessarily as a result of the event. Over the same period, nearly 900,000 people were treated and discharged by hospital staff working very hard to relieve suffering and improve health and quality. Further information is available from the following links:
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Last Updated 30/11/2009