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Serious and sentinel events report 2011/12

Each year, the Health Quality & Safety Commission releases a report on serious and sentinel events (SSEs) in District Health Board (DHB) hospitals. Commission Chair Professor Alan Merry looks at the 2011/12 figures and how we can learn from them

Serious and sentinel events reporting aims to encourage transparency and a ‘no blame’ culture. This means we can have an accurate picture of where things are going wrong, and put in place systems to reduce harm. It is also much more than that. It is a promise to patients that these tragic events will be robustly reviewed, to ensure appropriate care and treatment were provided and, where indicated, to improve systems and processes of care.

And this reporting is a safeguard for clinicians. By identifying and fixing systems failures we give clinicians greater confidence that they will be supported by the systems around them to practise safely. For the 2011/12 year, DHBs1 reported 360 SSEs, 3% fewer than the 370 recorded in 2010/11. Ninety-one patients died (86 in 2010/11), although not necessarily as a result of the adverse event that occurred.

SSEs included 170 falls, a 13% decrease from the 195 falls reported the previous year; 111 clinical management events, up from 105 in 2010/11; 18 medication errors, down from 25 the previous year; and 17 suspected inpatient suicides. There was an overall decrease in SSEs and specifically falls for 2011/12. This is very good news and represents a lot of hard work by DHBs to both report and prevent adverse events.

However, we have seen an increase in the number of cases of delayed treatment and suspected inpatient suicides. In 2011/12, 17 suspected inpatient suicides were reported by DHBs. The Commission has looked at the DHBs’ reviews of these deaths and found there is no clear trend evident – either in terms of whether numbers are increasing, or common factors.

These cases of delays in treatment show how critical it is for clinicians to follow up when tests have been ordered, referrals made, or further treatment recommended

International evidence shows that despite the best efforts of family, friends, other social agencies and mental health staff, tragically, some patients will commit suicide. However, it is important health services do everything they can to reduce these events and, when they occur, to investigate them. Each of these suicides has been subject to a robust process of review to ensure appropriate care and treatment were provided and to improve systems and processes of care to reduce the chances of such a tragedy occurring again.

The Commission is also working with the mental health sector to identify the best approach to reviewing and reporting serious incidents involving mental health service users. A working party of experts from the mental health sector (including consumer representation) has made recommendations to the Commission, and the Commission is discussing the implementation of these changes with the sector.

In 2011/12, 17 cases were reported to the Commission describing events in which system failures resulted in delays in the diagnosis of cancer, or in a similar serious outcome. There were 13 such events in 2010/11, eight in 2009/10, nine in 2008/09 and seven in 2007/08 – indicating a likely increasing trend. These cases of delays in treatment show how critical it is for clinicians to follow up when tests have been ordered, referrals made, or further treatment recommended. This is particularly important in today’s environment, in which people are increasingly seen by teams of health professionals.

The Commission will be looking at measures that can be put in place to reduce the likelihood of these sorts of events taking place. The importance of following up needs to be top-of-mind for clinicians at all times.

The importance of following up needs to be top-of-mind for clinicians at all times

This year, a national reportable events policy has introduced a change to the way SSEs are reported to the Commission. Previously, there was no requirement for DHBs to report the outcome of a review to the Commission, meaning lessons from events were often not shared. There is now a requirement for organisations to report to the Commission the key findings and recommendations of reviews of events that occurred from 1 July 2012. Future SSE reports will be able to discuss in greater detail issues such as contributory causes and what has been learnt from the events.

Several health and disability organisations other than DHBs are in discussion with the Commission about potentially reporting SSEs in the future. They include members of organisations such as the Disability Support Network, Care Association NZ, Hospice NZ and Ambulance NZ. Individual providers such as Mercy Hospital Dunedin are also in discussions with the Commission.

The Commission is working closely with the health and disability sector on a number of initiatives, including a national patient safety campaign to be launched in the first half of 2013. Initially the campaign will focus on preventing harm in the following areas:

  • infection prevention and control
  • surgery – reducing perioperative harm 
  • medication 
  • falls.

The full SSE report is available on the Commission’s website:


  1. A serious adverse event is one that leads to significant additional treatment but is not life-threatening, and has not resulted in a major loss of function. A sentinel adverse event is life-threatening or has led to an unexpected death or major loss of function.
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