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Launch of the Sentinel Events Workbook

18 February 2002
Hon Annette King Speech Notes

Tonight’s official launch of the Sentinel Events Workbook is an important step in building a safety culture in the New Zealand health and disability sector.

The Workbook will help providers by providing logical and easy-to-follow advice about what a ‘safety culture’ could mean in their own workplace.

I would be very surprised if there is anyone in this audience who does not believe this is welcome, but I believe tonight’s launch is also important for another reason.

Last Thursday, in opening the Counties Manukau Integrated Care 2002 conference, I discussed the importance of leadership in developing the exciting and innovative concept of integrated care in New Zealand.

Tonight I want to mention leadership again, in another area this time. In terms of developing a safer culture in health in New Zealand, it is absolutely fundamental that we rid ourselves of our fascination with needing to name, blame or shame someone when something goes wrong.

How can we possibly expect to develop a committed and positive health workforce if the workforce believes it will be on trial whenever a mistake occurs?

Mistakes will occur. It is inevitable in a sector as diverse and as complicated and as subject to pressure as the health sector. The important thing should be to learn from mistakes, not to name, blame and shame someone who has perhaps made a genuine error.

But before I say more about that, to return first to the Workbook, it represents a practical response where it is needed and a meaningful way to back up this Government’s commitment to a safety culture.

The Workbook will be an excellent learning prompt for DHBs and for individual workplaces at all levels, nationally and regionally.

It provides a number of common quality improvement tools and charts, and integrates these with methodologies to allow a comprehensive approach to analysing mistakes and errors.

As many here know, the Workbook has resulted from a recommendation to the Director-General of Health from the Sentinel Event Working Party in September 2001. The Working Party recommended development of resources to guide health and disability staff through steps they need to take when investigating mistakes, and how to apply lessons learned to prevent recurrences.

The Workbook is funded by the Ministry of Health and is published by Standards New Zealand. It is to be used in conjunction with the Ministry of Health’s Reportable Events Guidelines.

It is my hope, and the Workbook’s premise, that standard methodologies for investigating sentinel events, the most serious of errors and mistakes, will help replace the fear of being “named, blamed and shamed”.

The Workbook, in fact, recognises that discovering and reporting mistakes, errors and close calls, should not be punished, but encouraged and rewarded.

While the Workbook is designed to assist with investigating rare events, the 1 in 1000 reportable events that is a sentinel event, the principles and suggestions it contains will also be useful for preventing smaller mishaps.

The cultural change we are seeking will only be achieved through the cumulative effect of both small and big changes.

If left unchecked, the fear of being “blamed, named and shamed” will undermine the attempt to achieve a safety culture.

The culture of “blame and shame” leads to mistrust, an inability and unwillingness to discuss and address problems, and an unnecessary use of resources that could be put to more effective use delivering health and disability services.

Deficiencies in processes, rather than the actions of individuals, are the most common reason for errors and mistakes. This is an absolutely crucial starting point if we are to move to a safety culture.

I read the following comment in Issue 49 of The Specialist, the magazine of the Association of Salaried Medical Specialists. “Recruitment and retention require a supportive environment. They are severely threatened by the blame and shame approach … Much of the solution to this rests with politicians and the media. And it would not cost a cent to turn around.”

As I told the ASMS executive last week, I agree, and I will certainly do what I can to provide the environment for this to happen.

The Workbook is also a product of, and illustration of, the need for better collaboration and cooperation in the health sector. Indeed, the Workbook has only been possible because of extensive consultation with the sector, and cooperation within the sector in putting it together. It shows the importance of breaking down professional silos, and recognising that medical staff, quality experts and health managers all have a role to play in fostering a safety culture.

There has been close cooperation between the Ministry and Standards New Zealand in producing the Workbook. Standards New Zealand is having a vital role in promoting several publications laying the groundwork for a safety culture, including the recently launched Health and Disability Safety Standards.

Other changes associated with the Sentinel Working Group are also occurring. A Child and Youth Mortality Review Committee has now been established, and nominations have been called for the National Health Epidemiology and Quality Assurance Advisory Committee. Both committees are based on the premise that greater clinical input in investigating events will help identify solutions and improvements.

The most effective way of realising the goal of minimising mistakes and errors is to have a trusting working culture that allows errors to be investigated and addressed in a thoroughly open manner. The alternative of a closed and untrusting approach is in no one’s best interests, least of all patients.

The cultural change can’t be reached overnight or as the result of just one publication, but this Workbook will help provide the groundwork.

I am very pleased to be here celebrating this launch. I applaud the hard work that has gone into the Workbook and everyone involved in the project can be proud of what has been produced. I will continue to watch developments regarding patient safety with great interest, and will do my bit to provide leadership where that is needed.

Achieving a safety culture in health is not just an issue of interest to experts only. It is a real issue for the thousands of New Zealanders who access health and disability services each year.

Many patients are naturally, and understandably, apprehensive when they need care, but this Workbook will play its part in providing reassurance and reinforcing trust and confidence in our health and disability services. That is something we can all applaud.

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