The Waikato DHB sentinel and serious event summaries are on http://www.waikatodhb.govt.nz/wdhb/default.asp?Content=1427 along with information pertaining to the Waikato DHB.
** High Priority **
Date: 20 February 2008
WAIKATO FOCUSSED ON QUALITY AND SAFETY
Waikato District Health Board's 94 sentinel and serious events suggest an organisation with a heightened focus on quality and safety, chief executive Craig Climo said today.
Waikato DHB reported 19 sentinel and 75 serious events between July 1, 2003 and June 30, 2007.
In the same period Waikato DHB's health and hospital services' provider arm Health Waikato discharged from its hospitals 329,646 patients; 85 per cent of them from Waikato Hospital in Hamilton.
The events included:
* 28 deaths; 23 of
which Waikato DHB's actions or inactions may have
* 26 events which resulted in no known harm to the patient
* Nine events which caused extended hospitalisation or treatment, but no known long-term harm to the patient
Type of event:
* Seven mental health
* 22 events in rural hospitals
* 65 events at Waikato Hospital
* Two events out of Waikato DHB's control
* Two events that involved power outages
"Waikato DHB has long encouraged open reporting of events that allows us to consider all factors that could have influenced the situation and that give us the opportunity to identify and address," said Mr Climo, who joined Waikato DHB as chief executive in August last year.
"I've been very impressed with the approach at Waikato DHB. The team here believe in open reporting and learning from incidents and I absolutely support that."
Chief medical advisor Dr Tom Watson said many of the patients involved in the adverse events were aware or had been informed that an event had occurred.
"While we know many of the patients will be aware of what happened, we cannot guarantee that in every case though."
An 0800 line (0800 100 178) has been set up so any person who wishes to further discuss their actual or possible involvement can do so, said Dr Watson.
Those ringing through are asked to leave their name, daytime contact number, the dates they were in hospital, their National Health Index (NHI) number (if known), their doctor's name and any other details which may be useful. They will be contacted within two working days.
Dr Watson said he was convinced DHBs with larger numbers of events reported, and greater details about the events, reflected better local systems for reporting and investigating and probably a superior safety culture.
"That's certainly the case at Waikato.
"We have significantly improved the levels of incident reporting over the past 10 years. However there is still room for improvement," he said.
Mr Climo said Waikato DHB was six months into a structured programme to improve its reporting processes further, educating staff and improving the technology associated with the process.
"Such is our commitment to quality and safety; we have also volunteered to lead a Quality Improvement Committee national project to improve incident reporting and incident review nationwide.
"Where we need to improve our game somewhat is in ensuring that recommendations arising from incidents are monitored to completion," he said.
Dr Watson said initiatives were already in place to do this. Among them included better board oversight and greater clinical involvement in the processes.
"Humans do make mistakes, no-one is infallible and whilst we accept the devastating outcomes on patients and their families; the health professionals involved are hugely affected too. For some it can lead to leaving a previously successful career due to the impact of such an incident.
"Health Waikato is a large provider of secondary and tertiary services and as such operates in a complex clinical environment. Patients are often already too sick to help by the time we see them and in some cases almost beyond our ability to help them," said Dr Watson.
"For this reason it's sometimes difficult to identify the extent to which our actions or inactions contributed to the 28 deaths.
"The range of diagnostic tests and health-care treatments is constantly expanding and hospital staff do an outstanding job in providing first-rate care to patients. Every month we receive hundreds of compliments about the care we provide to patients and we must not lose sight of that."
Dr Watson said he would be devastated if publicity around the release of the sentinel and serious events stopped any clinical staff from reporting incidents because their mistakes were made public.
"We rely on that honesty. Using the data inappropriately may adversely affect the culture of safety and openness that we have steadily built up in Waikato.
"Waikato DHB staff and managers have been very supportive of the serious event review process, and in addition often request review of events which do not meet the definitions of serious and sentinel events. There is a strong commitment to learning from adverse events," he said.
Last week David Galler, the principal medical adviser to the Minister of Health, was glowing in his praise of Waikato DHB saying on National Radio that the organisation had a "magnificent reporting system that goes all the way through to what the event was, the classification of the event, a description of it, what steps were taken to intervene, the follow up result and what was learned from the event."
He said Waikato's system was a "magnificent template" and the organisation had a "healthy reporting culture".
** High Priority **
Date: 20 February 2008
HEALTH WAIKATO COMMITTED TO QUALITY CARE
An enhanced focus on quality and safety was already top of the agenda for Health Waikato before today's publication of serious and sentinel events, says chief operating officer Jan Adams.
A consultation document 'Where to Now? Quality and Safety' was sent out to all staff last month with submissions closing February 8.
"We are committed to providing quality care and to monitor and continuously improve our services by enhancing all aspects of the patient/client journey," she said.
"It is vital we engage in the process of enhanced quality and safety and are able to do so within a culture of open communication and teamwork."
Every submission received was supportive of the approach in the paper which included establishing a Health Waikato Quality and Safety Agenda.
As part of that agenda, leadership walk rounds are due to start in Waikato Hospital next month then be rolled out to the rural hospitals, mental health and addiction services and continuing care facilities.
Executive or leadership walk rounds are used world wide to improve the safety culture in hospitals.
The aim is to create a culture that puts patient/client safety at the centre.
Mrs Adams will lead the walk rounds which would also involve executive leaders across the Waikato DHB.
"This presents an excellent opportunity for executives to visit areas they would usually not see and understand the key concerns that staff may have and to agree tangible action points that takes joint ownership of the issues and develops processes to resolve them," she said.
** High Priority **
THE PROCESS FOR REVIEWING SERIOUS EVENTS
Waikato DHB introduced processes for reviewing serious events, using Root Cause Analysis, in 2001 after the Quality and Risk Manager Barbara Crawford attended a conference where the methodology was presented. This was modified for Waikato DHB's use and implemented.
The process involves discussions held with staff involved in the event, following which the root causes and other learnings are identified by a member of the Quality and Risk Service in consultation with the staff involved.
An action plan is developed - again in consultation with the staff involved to ensure that the proposed actions will assist in preventing recurrence of a similar event. The Serious Event Panel, chaired by the Chief Medical Advisor and including senior medical, nursing, Quality and Risk staff and managers, meets to review the Root Cause Analysis and the Action Plan to make any amendments and approve them.
The Mental Health Service has its own Serious Event Panel to review Mental Health Services events.
The Quality and Risk Service maintains a central record of all incidents and serious and sentinel events and provides quarterly reports to the Clinical Board which monitors achievements of the agreed actions.
Where the information provided in the Event Tables released to the media is missing, this means that documented evidence of the implementation of these actions has not been received by the Quality and Risk Service.
The actions may have been taken, but are not signed off until documentary evidence has been received.
Twenty four serious and sentinel events from 2006-2007 representing 0.027 per cent of discharges (86,185), were reviewed.
That, compared with the national figure for all DHBs of 0.022 per cent, means that Waikato DHB has slightly higher reporting levels but is similar to other DHBs in that this figure is approximately 10 times less than the figure quoted in the Peter Davis study. The Davis study found that 0.2 per cent of patient admissions resulted in a preventable adverse event.
FACTS AND FIGURES ABOUT WAIKATO DISTRICT HEALTH BOARD
Waikato DHB is responsible for planning, funding and providing quality health and disability support services for the 353,460 people living in the Waikato DHB region. It has an annual turnover of $915 million and employs more than 5300 people.
Health Waikato has seven divisions across five hospital sites, two maternity and continuing care hospitals, a mental health facility in Hamilton and 21 community bases offering a comprehensive range of primary, secondary and tertiary health services.