Serious and Sentinel Events Report 2010/11

Serious and Sentinel Events Report – Making Our Hospitals Safer

A total of 377 serious and sentinel events occurred in New Zealand’s public hospitals in 2010/2011 – a rate of more than one for every day of the year.

The Health Quality & Safety Commission says some people died and many suffered serious injury or disability as a result of these events, and it’s calling on health providers and those working in health and disability services to learn from the mistakes of the past.

“The people involved in these 377 events were let down by the system that exists to protect them,” says Professor Alan Merry, the Commission’s Chair.

“We should view these events through the eyes of patients and their families, and acknowledge that many of them should never have happened.”

The Commission has released the 2010/2011 report of serious and sentinel events in the country’s District Health Boards (DHBs). 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.

Of the 377 events reported, 86 patients died, although not necessarily as a result of the adverse event which occurred.

Professor Merry says New Zealand has an excellent health and disability system, with more than 2.7 million people treated in public hospitals or as outpatients each year and very few occasions of serious harm.

“The fact remains, however, that a small number of people are injured in the course of receiving treatment and an even smaller number lose their lives as a result of something that happens to them in hospital.

“It’s not about apportioning blame – it’s about improving the quality and safety of our health and disability services.”

The Commission took over responsibility for collating information and reporting on serious and sentinel events when it was established in 2010. This report is the Commission’s second, and the fifth by DHBs. It does not capture all adverse events that occurred in public hospitals, only those considered by each DHB as serious or sentinel events.

According to the figures, 195 falls were reported as serious and sentinel events in 2010/11, up from 130 falls reported for the previous year. A total of 25 medication errors were reported, along with 108 clinical management incidents which included:

• delays in responding to a patient’s changing or deteriorating condition

• poor communication between health professionals

• delayed diagnoses due to failings in referral processes and the reporting of results.

Outpatient suicides have not been included in this report, unlike previous years, as the Commission is of the view that these events are very different from the other events reported. The Commission will be working with the mental health sector over the next year to find better ways of reporting and reducing suicides.

Professor Merry says the high number of falls is of particular concern and the Commission is working closely with the sector to prevent and reduce harm from falls. It is also working on initiatives to reduce medication errors and health care associated infections, promote use of the World Health Organization’s safe surgery checklist, and to improve the quality of data and reporting of adverse events.

“The Commission’s role is to improve quality and safety in New Zealand’s health and disability sectors, and a key aspect of that is to reduce harm from preventable errors. While some adverse events are outside our control and will always occur, there are many other preventable incidents which we should aim to erase completely.”

He says some DHB Boards are now regularly reporting adverse events during open meetings, and he applauds their transparency.

Professor Merry urges health professionals to familiarise themselves with the report’s findings and to look at how they can make the services they provide safer for patients.

“It’s not acceptable to keep making preventable errors and all of us who work in health need to redouble our efforts to ensure patients receive the best and safest care,” he says.

Attached are:

• the full report

• report factsheet

• table of DHB events

• questions and answers

Definitions:

A serious adverse event requires significant additional treatment but is not life threatening and has not resulted in a major loss of function.

A sentinel adverse event is life threatening, or has led to an unanticipated death or major loss of function.

Note: some of the adverse events included in this serious and sentinel events report are subject to further review, and numbers may change.

ENDS

SSE_main_report_final_20_Feb_2012.pdf
SSE_factsheet_final_20_Feb_2012.pdf
SSE_cases_2010_11_FINALv1.docx

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Serious and Sentinel Events 2010/11

Questions & Answers

20 February 2012 / Embargoed until 12.30pm

What are 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. The serious and sentinel events report published by the Health Quality & Safety Commission does not capture all adverse events that occurred in public hospitals, only those considered by each District Health Board (DHB) as serious or sentinel.

How many cases of potentially preventable injuries and deaths have occurred in DHB hospitals nationwide?

A total of 377 serious and sentinel events occurred in New Zealand’s public hospitals in 2010/2011, compared with 318* reported by DHBs in 2009/10. Of the 377 events reported, 86 patients died, although not necessarily as a result of the adverse event which occurred.

Adverse events reported by DHBs for 2010/11 include:

• 195 falls, up from 130 falls the previous year

• 25 medication errors

• 108 clinical management incidents, involving delays in responding to a patient’s changing condition, poor communication between health professionals, and delayed diagnoses

More than 2.7 million people are treated in public hospitals or as outpatients each year, and serious harm to patients is rare. However, this report shows that too many people continue to be injured in the course of receiving treatment.

* Excluding outpatient suicides.

What is an acceptable, or expected, number of adverse events within hospitals?

There is a difference between what is acceptable and what is expected. International studies show 10 to 15 percent of hospital admissions can be associated with an adverse event – although about half of these adverse events are not considered preventable [Wilson et al. Quality in Australian Health Care Study. 1995. Med J Aust. 163.]. Many of the events are known complications of treatment and are not preventable with current knowledge. This means we can expect some adverse events to remain outside of our control and to continue to occur.

However, in terms of what is acceptable – the Commission believes that many of the events reported in the 2010/11 report should never have happened. They were preventable. The Commission is paying particular attention to those types of events and is working with DHBs and others in the health and disability sector to reduce harm from such things as falls, medication errors, infections, and also improve the reporting of data.

Modern health care is extremely complex, with powerful medicines and new methods of treatment constantly being developed. The risk of human error also increases as medical care becomes more complex, which is why DHBs and others have sophisticated systems for checking and reviewing safety. Keeping in mind the large number of patients treated each year, it is still rare in New Zealand’s health system for a serious adverse event to happen.

Given the variation in the number of events between DHBs, can we assume some hospitals are safer than others?

The number of incidents is not an indicator of a hospital’s safety. A large number of incident reports can also signal that staff are very focused on safety and are actively reporting incidents. Larger specialist hospitals will also have higher numbers of incidents because they see more patients and deal with more complex cases. Conversely, a low number of reported cases may reflect the outcome of a very successful risk management programme, or a less mature or developing safety programme.

However, the Commission is concerned about significant variation in reporting and is actively working to improve the quality and consistency of data collected across the health and disability sector. Reliable data is essential if DHBs and other health providers are to make changes that will improve safety.

Shouldn’t health professionals be accountable when things go wrong?

They are. There are separate processes that hold clinical professionals accountable for the quality of their work and maintaining professional standards.

It is also important to note that errors sometimes occur because systems are not error-proof. Systems need to be as safe as possible – the safest places have the strongest systems. The reporting of incidents is about continually looking at our systems and the ways we can improve them to minimise the risk to patients in the future. It’s not about apportioning blame.

What is the Commission doing to prevent adverse events from occurring?

The Commission is working with health and disability care providers on a number of initiatives to improve patient safety, including:

• medication safety – the rollout of a standardised national medication chart and formal medicine reconciliation process across DHBs, and development of a range of e-medicine projects

• infection prevention and control – partnerships with Auckland DHB to deliver a national hand hygiene programme and Counties Manukau DHB for a project to reduce central line associated bacteraemia (CLAB)

• falls – working with the health and disability sector to develop strategies to reduce and prevent harm from falls

• enhancing the engaged use of the World Health Organization’s Safe Surgery Checklist.

Note: some of the adverse events included in this serious and sentinel events report are subject to further review, and numbers may change.

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