Health Quality & Safety Commission | Serious and Sentinel Events 2011/12
The Health Quality & Safety Commission has released the 2011/12 report of serious and sentinel events (SSEs) in District Health Board hospitals.
The report shows 360 SSEs were reported, 3 percent fewer than the 370 recorded in 2010/11. Ninety-one patients died (86 in 2010/11), although not necessarily as a result of the adverse event which occurred.
Adverse events reported by DHBs for 2011/12 include:
- 170 falls, a 13 percent decrease from the 195 falls reported the previous year, and the first decrease since reporting began. Falls represent 47 percent of all SSEs reported for 2011/12
- 111 clinical management events, up from 105 in 2010/11. These represent 31 percent of all SSEs reported for 2011/12, and include 17 cases of delayed treatment due to failures in hospital systems – an increasing trend
- 18 medication errors, down from 25 the previous year. These represent 5 percent of all SSEs for 2011/12
- 17 suspected in-patient suicides, up from three the previous year. These represent 5 percent of all SSEs for 2011/12.
The Commission’s Chair, Professor Alan Merry, says not all the events described in the report were preventable, but many involved errors that should not have happened.
“In some tragic cases errors resulted in serious injury or death. Each event has a name, a face and a family, and we should view these incidents through their eyes.”
Professor Merry welcomes the overall decrease in SSEs and specifically falls for 2011/12.
“This is very good news and represents a lot of hard work by DHBs to both report and prevent adverse events,” he says.
“At the same time, however, we have seen an increase in the number of cases of delayed treatment and suspected in-patient suicides.”
He says the greater number of suspected in-patient suicides this year does not appear to be part of an increasing trend. Most of the cases involved mental health patients, although at least two were patients who had been on general wards.
“The Commission has looked at the reviews into these very sad events and there appear to be no common factors. There is also no evidence of a trend of increasing in-patient suicides.”
Over the past five years, in-patient suicide numbers have varied – 16 in 2007/08, 8 in 2008/09, 4 in 2009/10, 3 in 2010/11 and 17 in 2011/12.
The Commission’s Reportable Events Clinical Lead, Dr David Sage, says the cases involving delays emphasise two things – how important it is for clinicians to follow up when tests have been ordered, referrals made, or further treatment recommended; and the importance of formal reconciliation procedures when organising biopsies and appointments.
“The Commission is looking at measures that can be put in place to reduce the likelihood of these types of events. For example, making sure patients are full partners in the management of their care – so they too are aware if there needs to be a further test, result from a specimen, or referral to another specialist,” says Dr Sage.
Professor Merry says despite the gains made in 2011/12, too many people are still being harmed in the course of receiving health care.
“This is not about apportioning blame,” he says. “This is about learning from our mistakes and making our health and disability services safer so patients receive the care they need, without needless harm. This SSE report contributes to that by stimulating discussion about adverse events and identifying areas for improvement.”
The 2011/12 SSE report is the Commission’s third, and the sixth by DHBs. It does not include all adverse events that occurred in public hospitals, only those which DHBs consider serious or sentinel.
This year, a national reportable events policy has introduced a change to the way SSEs are reported to the Commission. Previously, there was no requirement for DHBs to report the outcome of a review to the Commission, meaning lessons from events were often not shared. There is now a requirement for organisations to report to the Commission the key findings and recommendations of reviews of events that occurred from 1 July 2012. Future SSE reports will be able to discuss in greater detail issues such as contributory causes and what has been learnt from the events.
In addition, a number of health and disability organisations other than DHBs are in discussion with the Commission about potentially reporting SSEs in the future. They include members of organisations such as the Disability Support Network, Care Association NZ, Hospice NZ and Ambulance NZ. Individual providers such as Mercy Hospital Dunedin are also in discussions with the Commission.
The Commission is working with the mental health sector to identify the best approach to reviewing and reporting on suicides involving mental health service users, and in future there will be a separate report covering these events.
The Commission is also working closely with the health and disability sector on a number of initiatives, including a national patient safety campaign to be launched in the first half of 2013.
A serious adverse event is one that leads to 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 unexpected death or major loss of function.
 In the 2010/11 report, DHBs initially reported 377 cases but later withdrew seven cases after completing reviews which found those cases no longer fell into the category of ‘serious’ or ‘sentinel’. Some of the adverse events included in the 2011/12 SSE report are also subject to further review, and numbers may change.