Serious and Sentinel Events Reported By District Health Boards - 2007/08 - Resources

Resources

Serious and Sentinel Events Reported By District Health Boards - 2007/08

Summary

Sentinel and Serious Events Reported by District Health Boards in the 2007/08 year provides the second 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.

For the reporting year 2007/08 District Health Boards reported 258 people treated in their hospitals were involved in an adverse clinical event that was actually or potentially preventable. Of this total, 76 died during the admission or shortly afterwards, though not necessarily as a result of the event.

Over the same period, nearly 900,000 people were treated and discharged by hospital staff working very hard to relieve suffering and improve health and quality.

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.

Hospitals have always collected data about the incidents; the compilation of this report summarising events in this form is part of a programme responding to the Health and Disability Commissioner’s challenge and to encourage open and transparent reporting of incidents when something goes wrong.

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

This report is released annually by the Quality Improvement Committee.

Media Statement and Questions and Answers

Media Statement: National reporting framework for serious and sentinel events (23 February 2009)

Questions and Answers (Word, 127 KB)

The QIC Serious and Sentinel Event Report 2007/08

The QIC report is are available in Word and PDF format below:

Serious and Sentinel Events in New Zealand Hospitals 2007–2008 (Word, 440 KB)
Serious and Sentinel Events in New Zealand Hospitals 2007–2008 (PDF, 129 KB)

Event Summaries by District Health Board

The DHB event reports are available in Word and PDF format below:

DHB Summary of Serious & Sentinel Event Report 2007/08 (Word, 772 KB)
DHB Summary of Serious & Sentinel Event Report 2007/08 (PDF, 364 KB)

Page last updated: 23 February 2009