National reporting framework for serious and sentinel events

Media Release

23 February 2009

National reporting framework for serious and sentinel events

“Any preventable error in a hospital is unacceptable and regrettable.”

Patrick Snedden, Chair of the Quality Improvement Committee today released the second consolidated report of serious and sentinel events* across the 21 District Health Boards.

Mr Snedden says that in the 2007-2008 year, DHBs reported 258 people treated in New Zealand hospitals were involved in potentially preventable serious or sentinel events that resulted – or could have resulted in – serious harm. Of this total, 76 died during the admission or shortly afterwards, though not necessarily as a result of the event

“Over that same period, nearly 900,000 people were treated and discharged by competent and professional staff working very hard to save and improve lives. For most people, the outcome is good and anticipated, however any level of preventable harm is regrettable and gives us impetus for improvement.

“Sometimes, despite people’s best efforts, things go wrong. When they do, we need to be open with patients and their families, do what we can to correct the situation and we need to support the clinicians and health professionals involved.

“We also need to investigate impartially, learn what happened and – most of all –we need to share the information try to stop it happening again.”

Mr Snedden says this is the second year the statistics have been collated and released in this way, and the figures show a rise in the number of events reported.

“Hospitals have always collected this data. Last year we learned more about the value of sharing lessons learned with other DHBs and have therefore started to introduce a new, national incident management framework to record the incidents and provide detailed summaries of outcomes and lessons learned.

“Our aim is to improve safety by encouraging open and transparent reporting of events when something goes wrong. What we’re learning is being translated to system and process improvements in hospitals to reduce the risk of these events.”

Mr Snedden says part of this process is a system to make real time information about serious and sentinel events available on line to clinicians so the benefits of these improvements can be shared.

“We have good, safe hospitals staffed by highly skilled people that provide a good quality of care – this is about making it even better.”

For more information:
Karalyn van Deursen: 04-496-2115, 021 832 459

View the report in the Resources section - Serious and Sentinel Events Reported By District Health Boards - 2007/08.

* Definitions:
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.

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.