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Commentary On Sentinel & Serious Events Reported By District Health Boards - 2006/07
Summary
Sentinel and Serious Events Reported by District Health Boards in the 2006/07 year provides the first consolidated report about serious and sentinel events across New Zealand’s 21 District Health Boards.

A serious or sentinel event has, or has the potential to result in, serious lasting disability or death, not related to the natural course of the patient’s illness or underlying condition.

Although hospitals have always collected data about the incidents, this is the first time the data has been compiled into one report with detailed summaries of each serious and sentinel event. The aim is to improve safety by encouraging open and transparent reporting of incidents when something goes wrong.

The report shows that in 2006-2007, 182 people treated in to New Zealand hospitals were involved in actual or potentially preventable clinical incidents that resulted – or could have resulted in – serious harm or death. Of these, 40 died as a result of the incident.

Over that same period, more than 800,000 people were treated and discharged by competent and professional carers working very hard to save and improve lives.

In 2007 the Health and Disability Commissioner issued the sector a challenge to come up with a system to report and measure these events and provide comparative statistics as part of the process of making patient care safer.

The Quality Improvement Committee was set up in February 2007 to provide independent advice to Parliament and make recommendations on quality improvement. A national framework for incident management is one of QIC’s five quality improvement priority projects and so far, $20 million has been allocated to these programmes.

This report will be issued annually by the Quality Improvement Committee.
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Document availability
This report is available in Word format below:

Commentary On Sentinel & Serious Events Reported By District Health Boards - 2006/07 (Word, 244 KB)
Questions and answers
Serious And Sentinel Events – Questions & Answers (Word, 123 KB)

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District Health Board data
District Health BoardSentinel and Serious Events Data
Northland DHBNorthland DHB Sentinel Events 2005-07 (Excel, 143 KB)
Waitemata DHBWaitemata DHB Sentinel Events 2004-08 (PDF, 129 KB)
Auckland DHBAuckland DHB Sentinel Events 2003-07 (PDF, 201 KB)
Counties Manukau DHBCounties Manukau DHB Sentinel Events 2003-07 (Word, 119 KB)
Waikato DHBWaikato DHB Sentinel Events 2003-04 (PDF, 2 MB)
Bay of Plenty DHBBay of Plenty Sentinel Events 2005-07 (PDF, 135 KB)
Lakes DHBLakes DHB Sentinel Events 2004-07 (Word, 50 KB)
Tairawhiti DHBContact Tairawhiti DHB for data
Taranaki DHBTaranaki DHB Sentinel Events 2005-07 (Word, 45 KB)
Hawke's Bay DHBHawke's Bay DHB Sentinel Events 2003-07 (PDF, 1 MB)
Whanganui DHBWhanganui DHB Sentinel Events 2003-04 (Word, 23 KB)
Whanganui DHB Sentinel Events 2004-05 (Word, 25 KB)
Whanganui DHB Sentinel Events 2005-06 (Word, 26 KB)
Whanganui DHB Sentinel Events 2006-07 (Word, 29 KB)
MidCentral DHBMidcentral DHB Sentinel Events 2006-07 (Word, 48 KB)
Wairarapa DHBWairarapa DHB Sentinel Events 2005-07 (Word, 32 KB)
Capital & Coast DHBCapital & Coast DHB Sentinel Events 2006-07 (Word, 56 KB)
Hutt Valley DHBHutt Valley DHB Sentinel Events 2003-07 (Word, 82 KB)
Nelson Marlborough DHBNelson Marlborough DHB Sentinel Events 2002-2007 (PDF, 53 KB)
West Coast DHBWest Coast DHB Sentinel Events 2003-07 (Word, 38 KB)
Canterbury DHBCanterbury DHB Sentinel Events 2004-05 (Word, 61 KB)
Canterbury DHB Sentinel Events 2005-07 (Word, 95 KB)
South Canterbury DHBSouth Canterbury DHB Sentinel Events 2003-07 (Word, 41 KB)
Otago DHBOtago DHB Sentinel Events 2006-07 (Word, 69 KB)
Southland DHBSouthland DHB Sentinel Events 2004-07 (Word, 87 KB)

Related information
Media release: National reporting framework for serious & sentinel events (20 February 2008)

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Page last updated: 22 February 2007