Kupu Taurangi Hauora o Aotearoa

November 2010

Making Our Hospitals SaferSerious and Sentinel Events 2009/2010

Report released 17 November, 2010

New Zealand has an excellenthealth system

However, for a small number of people events happen that:

cause harm, or have the potential to cause harm

76-year-old woman

In hospital recovering well from a chest infection Assessed as a risk for falls, should mobilise only with staff assistance Rang buzzer - no response Got out of bed, slipped on a wet floor, fractured hip Needed surgery and longer hospital

stay

Assessed for planned eye surgery Follow-up appointment notification not

sent Surgery delayed Considerable additional eye damage

25-year-old woman

DHBs report each year

Serious adverse eventrequires significant additional

treatment, but is not life threatening, no major loss of function

Sentinel adverse eventlife threatening, or led to death or

major loss of function

These events are:

traumatic often tragic distressing costly for the health care system

Onus is on all of us to learn from them

2009/2010 year

374 people in serious or sentinel event 127 died during admission or shortly afterwards 64 of these deaths were through suicide

Over same period

Nearly 1 million people treated and discharged 1.7 million outpatient discharges

Sentinel or Serious Events, by DHB, 2007 to 2010*

DHB Number of reported serious or sentinel events2007/08 2008/09 2009/10

Northland 5 7 4Waitemata 11 20 17Auckland 30 31 32Counties Manukau 23 29 38Waikato 36 60 52Bay of Plenty 5 5 13Lakes 6 3 7Tairawhiti 3 7 3Taranaki 7 2 7Whanganui 4 7 9Hawke’s Bay 7 5 9MidCentral 2 8 18Hutt Valley 7 10 12Wairarapa 2 2 4Capital & Coast 16 22 18Nelson Marlborough 5 6 1West Coast 11 2 4Canterbury 41 44 69South Canterbury 12 7 9Otago 7 20 39Southland 18 11 9Total 258 308 374

Most common events 2009/2010

Falls 34% Clinical management problems 33% Suicide 17%

Percentage of All Event Types

33%

5%

34%

1%

2%

4%

17%

2%1%

1%

Clinical Managementproblems

Falls

Suicide

Medication error

Assault on patientRetained instruments/swabs

Wrong patient, site, procedure

AWOL patient

Hospital-acquired infectionOther

Classification of Serious and Sentinel Events in the Clinical Management Category 2009/10Classification 2009/10

Number of events

% Events

Diagnosis (including delayed and misdiagnosis) 14 11

Treatment (including delayed and inadequate treatment) 23 18

Monitoring/observations (not performed and/or actioned) 13 10

Procedure-associated event or complication 31 25

Investigations (delayed, not ordered or actioned) 5 4

Discharge and transfer 2 2

Other 13 10

Multiple categories 25 20

Total 126 100

Pie graph of percentage of events associated with the death of a patient

50%

41%

1%

3% 3% 2%

Percentage of Events Associated with Death of a Patient

SuicideClinicalmanagementproblems

Other

Medication error

Hospital-acquired infectionFalls

Factors contributing to events

Failure to recognise clinical deterioration Medication errors Poor communication

Factors contributing to events

Failures in referral and recall processes Inadequate staff knowledge Inappropriate staff mix on acute wards

Initiatives in response to reporting

Most DHBs adopted WHO’s Safe Surgery checklist Many DHBs have strong falls prevention programmes

Initiatives in response to reporting

Improvements in clinical management (eg, early warning systems) Improved booking and referral processes Standardised process to reconcile medicines and reduce medicine handover errors planned

Continued focus on safety essential

We need to learn from events to continue to improve safety in our hospitals

Every health care worker is urged to read the full report – www.hqsc.govt.nz Feedback encouraged – info@hqsc.govt.nz

Thank you

Kupu Taurangi Hauora o Aotearoa

November 2010