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Safe care through strong systems

Each year, a report is released on the serious and sentinel events that occur in our hospitals. The Health Quality & Safety Commission has taken over responsibility for reporting this information. Chair Professor Alan Merry takes a look at the 2010/11 figures, and how we can learn from them

No clinician goes to work wanting to make a mistake, but as annual serious and sentinel events reporting shows, mistakes do happen.

It is generally accepted that even the most careful and caring of clinicians will make errors in practice, and at times these errors will result in harm to patients. Often, the root cause can be traced back to a systems failure – which is why making systems as safe as possible is a priority for the Health Quality & Safety Commission.

For the 2010/11 year, District Health Boards (DHBs) reported 377 serious and sentinel events. This included 195 falls (up from 130 falls reported for the previous year), 108 clinical management incidents, and 25 medication errors. There were 86 deaths, although not necessarily as a result of the event.

These events are tragedies for patients and their families. They also often greatly affect the medical professionals involved. It is important we learn from them, to increase patient safety and to give clinicians confidence that they will be supported by the systems around them to practise safety.

The publishing of serious and sentinel events data must be more than a recitation of numbers

The publishing of serious and sentinel events data must therefore be more than a recitation of numbers. The latest event findings have several recurring themes:

  • Delays in responding to a patient’s changing or deteriorating condition 
  • Medication errors, including incorrect doses and administration of drugs to which a patient was known to be allergic 
  • Poor communication between health professionals, resulting in harm to a patient 
  • Delayed diagnoses due to failings in referral processes and the reporting of investigation results.

The Commission is concentrating on a number of specific work programmes to support the health and disability sector to reduce the incidence of harm from preventable events by making systems safer.

These include the development of a central repository for serious and sentinel events; development of strategies to reduce harm from falls; the continued and enhanced use of the World Health Organisation’s Safe Surgery Checklist; the development of a national reportable events policy; promoting the use of the national medication chart, medication reconciliation and electronic medicines management, and improving infection prevention and control measures.

Until now, only DHBs have reported serious and sentinel events, and only those events that occurred in public hospitals. We all know, however, that adverse events can happen in any health and disability setting. The Commission hopes that eventually all health and disability providers, whether public or private, will report serious and sentinel events so we all can learn from them. We are still some way from achieving that level of engagement and transparency across the sector, but the work has begun.

The Commission is looking into providing a web-based training package free to all providers to help staff review serious events, and manage the process of open disclosure

The Commission has started discussions with organisations representing providers in primary care, aged residential care, home health care, private surgical hospitals, and disability service providers. This activity is an important part of the Commission’s work programme in the coming year.

For some providers, a significant commercial issue may arise if the Commission reports incidents by provider, and we need to work together to find ways to manage those concerns. While DHBs now have mature systems in place for the review of adverse events and have the resources available to conduct reviews, this is not the case for all health and disability service providers.

In recognition of this, the Commission is looking into providing a web-based training package free to all providers to help staff review serious events, and manage the process of open disclosure. I have every confidence in the ability of our health and disability sector to learn from these events and rise to the challenge of reducing harm to patients.

The report Making Our Hospitals Safer: Serious and Sentinel Events reported by District Health Boards 2010/11, as well as a separate document with information on individual cases, is available at

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