Preventing serious and sentinel events
Enough staff key to preventing serious and sentinel events
The Serious and Sentinel Events Report released today (November 17) demonstrates, yet again, that having enough appropriately skilled staff to provide safe care, is crucial in preventing patients dying or suffering a serious disability while in hospital, according to the New Zealand Nurses’ Organisation (NZNO).
The report, released by the Health Quality and Safety Commission, details the deaths or serious lasting disabilities sustained by patients, not related to the natural course of a patient’s illness or underlying condition – 374 across district health boards (DHBs) in the last year. This is the fourth year this information has been released and it builds on previous reports from the Quality Improvement Committee.
NZNO professional nursing adviser Kate Weston praised the release of the reports, which had led to significant improvements in quality and safety over the last four years. “The information in the reports details where and why these events occurred. This level of transparency is essential if we are to continue to enhance the quality of patient care and improve patient outcomes,” she said. “This approach is not about ‘blaming and shaming’. It is about learning from these events to put in place systems that reduce the chances of them happening again.”
Weston stressed that having the right number of staff with the right knowledge and set of skills in the right place at the right time was a critical factor in preventing serious and sentinel events.
“If a busy ward with high acuity patients does not have the right number and the right mix of qualified and experienced staff on the floor, then the chances of something going seriously wrong increase. Research shows this to be so. That’s why the Safe Staffing Healthy Workplaces Unit’s work on care capacity management is so important and is supported by NZNO and the Ministry of Health. This work is about ensuring DHBs have systems in place that can accurately measure the demand for nursing care and the number and mix of staff needed to meet that demand. At present, too many DHBs have outdated models for assessing how many nurses are required and this means too often staffing requirements are under calculated,” Weston said.
She pointed out that the majority of incidents in the latest report related to falls (34 percent) and clinical management problems (33 percent). “Patient falls can be an indicator of staffing shortages, with too few staff to observe patients closely enough. For example, a patient with mobility difficulties or who is in a confused state, who has been waiting for a long time for nurse to assist with toileting decides to try and get to the toilet on their own and subsequently has a fall. These patients are already compromised, so the consequences of a fall can sometimes be very serious,“ Weston said.
Clinical management problems were another significant category in the report. “This includes patient monitoring, early intervention if a patient begins to deteriorate, and appropriate leadership and deployment of staff. If there simply are not enough staff on the job, or the staff on the job are not sufficiently qualified or experienced, patient outcomes are going to be compromised,” Weston said.
“Ensuring adequate staffing levels across all shifts is an absolutely critical factor in reducing the number of serious and sentinel events. We can’t emphasise that enough,” she said.