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.