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New Zealand's serious and sentinel health events

Waikato DHB welcomes today's publication of New Zealand's serious and sentinel health events.

Health Waikato chief operating officer Jan Adams said the organisation actively encouraged reporting of any adverse event or any event that had the potential to cause harm.

"We've taken the approach that it's important to learn from the events that are known, and to fully review these so we can improve the provision of care to patients. It's important to take appropriate action to prevent recurrence of events," she said.

Waikato DHB had 60 serious and sentinel events, representing 0.06 per cent of total inpatient discharges. In the period July 1, 2008 to 30 June this year, more than 90,000 people received treatment at hospitals in Hamilton, Thames, Tokoroa, Te Kuiti and Taumarunui showing that while adverse events are of great concern, they are relatively rare.

Clinical management problems made up 39 per cent of reported events, falls 16 per cent and medication errors less than one per cent.

"We have skilled health professionals, managers and support staff and we will support them to continue to deliver safe and effective care to the people of Waikato," said Mrs Adams.

Of the 60 Waikato DHB events (http://www.moh.govt.nz/moh.nsf/indexcm/qic-sentinel-and-serious-events-report-0809) notified:

* 16 deaths including 12 in the mental health service, two as inpatients.
* 17 - mental health incidents (28 per cent)
* 10 - falls (16 per cent)
* 3 - wrong patient, site or procedure (5 per cent)
* 24 - clinical management (39 per cent)
* 1 - medication error
* 20 - other (33 per cent) this includes suicide in community, wrong body uplifted from mortuary, patient injured by bedrail, etc etc
* Of the 20 'other' seven were suicide in the community events

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Waikato DHB activity 2008/09 2007/08
Inpatient discharges 86,616 83,184
Surgical operations 21,686 20,704
Outpatient attendances 181,156 154,080
ED attendances 78,275 77,640
Patient meals 685,664 670,654
Meals on wheels 35,915 30,644

We are a pilot site or lead site for three national initiatives:
* national incident management reporting system
* optimising the patient journey programme in our operating theatres
* hand hygiene

Learnings and improvements identified from previous reviews:

* launched Patient Safety at Health Waikato - a continuous improvement
* identified six patient safety priorities for 2009
o reduce medication errors
o reduce patient falls
o ensure that clinical audit carried out in every clinical unit
o set up the Health Waikato mortality committee to reduce avoidable mortality
o improve hand hygiene practices
o implement a safe patient care programme
* recruited seven quality co-ordinators attached to each service area to strengthen quality initiatives and reduce error rates
* levels of observation policy renewed within Mental Health and Addiction Services
* clinical handover process improved
* changes made to the opioid drug protocol and subsequent staff education
* orientation includes learnings for specific events with services
* clinical audits undertaken regularly
* implementation of assessment care planning documentation
* hourly nursing rounds
* falls project launched
o set up a project that investigated the cause and then what was required to reduce the falls causing harm
o wards identified where the falls were occurring, then altered the lay out, removing the clutter
o identification of at risk patients made a requirement of the nursing assessment
o education rolling out across all areas about how to reduce falls, ward based champions identified
o reduced sloping of floors in the bathrooms
o trialing non slip socks
o building in ward rounds (hourly)that focus on pain and toileting
o purchased electric high low beds
o use of sensor mats at the bedside
o using hip protectors
o building in the requirement for mobile equipment to have castor brakes
* internal and external improvements made outside Henry Rongomau Bennett Centre, including fencing, gating, removal of dense shrubbery
* reviews around caseload allocation and keyworker roles in the community
* renewed focus placed on risk management training, a compulsory component of mental health staff training and education, with continuing audit and follow up to ensure staff attendance
* review and improvement of Mental Health and Addictions Service orientation programme.
* audit of time periods between discharge from inpatient service and time seen by community teams.
* review of discharge planning and ward discharge/exit procedures
* increased focus on relapse prevention planning (this was also a national KPI).
* development, implementation and education on Wh*nau Ora assessment process
* audits on documentation and review and revision of documentation procedures
* policies and procedures reviewed, developed and implemented to focus on reducing risk, these include:
o contact with family/whanau after an unexpected death or suicide of a service user
o assessment and management of consumers
o levels of observation
o providing safe services to clients with complex presentations to the Mental Health and Addictions Service

All deaths and adverse outcomes are regrettable.
* DHBs try to provide the best possible care for all patients.
* DHBs are concerned when a patient dies or is injured, and they investigate to see if something occurred that highlights aspects of their systems and processes that need to be improved.
* Patients themselves are the first to say that they want to prevent adverse events occurring in the future, and encourage and support the concept of learning from mistakes.
* It's important to remember that hundreds of thousands of people receive care and treatment in our hospitals every year without adverse incident.
* While adverse events are of great concern they are relatively rare.

It's not always possible to prevent adverse outcomes.
* Sometimes things go wrong despite people's best efforts.
* International studies have consistently found that 10 to 15 percent of hospital admissions can be associated with an adverse event but the vast majority of events reported are minor and do not result in harm or permanent harm to patients.

DHBs are constantly seeking ways to improve their performance.
* DHBs review deaths and adverse outcomes to find out what happened in each case and to identify areas requiring improvement (people, processes and systems).
* DHBs regard any preventable error as unacceptable and seek to learn from it.

An increase in reported adverse events does not necessarily mean an increase in actual events.
* An increase is expected as a result of the better reporting systems now in place.
* The number of reported adverse events is likely to increase further as reporting continues to improve.

The number of reported event per hospital is not an indicator of that hospital's safety.
* A large number of incident reports is also a sign of a high safety focus amongst staff.
* Larger specialist hospitals will also have bigger numbers because they see more patients and deal with more complex cases.
* Reporting systems also vary from hospital to hospital.


A health care event is an event or circumstance that could have led, or did lead, to unintended and/or unnecessary harm to a patient, and/or a complaint, loss or damage.

An adverse event is a health care event causing patient harm that is not related to the natural course of the patient's illness or underlying condition.

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

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

Open disclosure is the open discussion of adverse events with the affected parties and the associated investigation and recommendations for improvement.

Preventable describes an event that could have been anticipated and prepared for, but that occurs because of an error or some other system failure.

Root cause analysis is a method used to investigate and analyse a serious or sentinel event to identify causes and contributing factors, and to recommend actions to prevent a recurrence.

Medication errors are a common category of adverse event.


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