MDHB News

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

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. 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.

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 has begun 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.