Serious and Sentinel Events
What are Serious and Sentinel Events?
Every year in New Zealand, nearly 900,000 people will be treated and discharged from a hospital.
For a small number of people within this total, and despite safety
systems and the best intentions of clinical staff, events happen that
have the potential to harm or actually do harm patients. Most of these
events involve known complications of treatment and are not preventable
based on current knowledge. They include known side effects to
medication, known risks from surgery and unpredictable events such as
unknown allergic reactions.
In addition, a small number of events resulting in serious harm, death
or requiring significant additional treatment are potentially
preventable. These events are rarely the result of one unsafe act, but
usually the consequence of a chain of events set off by small
breakdowns in the process of caring for patients. Unfortunately, the
consequences can be tragic.
This report focuses on these potentially preventable serious and sentinel adverse events.
Clinical judgement has been used to further refine these categories so
that they reflect the serious and sentinel adverse events that are
considered preventable given current knowledge. For instance, a known
complication of surgery is an adverse event, but if it is not
preventable, it will not appear in this report.
The purpose of recording and investigating preventable adverse events
in hospitals is to understand why these events occur and take action to
try to prevent similar events happening in the future. Finding the
cause and contributing factors allows hospitals to improve systems and
processes and ultimately to improve patient safety.
Standardised, consistent systems for classifying and recording adverse
events are essential to this process. Hospitals in New Zealand and
around the world vary in the way they classify, collate and report
preventable adverse events, and are only now starting to standardise
their approach in this area. The Quality Improvement Committee is
leading this standardisation work in New Zealand.
Definitions
- A health care event is an event or circumstance that could have
led or did lead to unintended and/or unnecessary harm to a patient,
and/or a complaint, loss or damage.
- An adverse event is a health care event causing patient harm that
is not related to the natural course of the patient’s illness or
underlying condition.
- A serious adverse event has required significant additional
treatment but is not life threatening and has not resulted in major
loss of function.
- A sentinel adverse event is life threatening or has led to an unanticipated death or major loss of function.
- Open disclosure is the open discussion of adverse events with the
affected parties and the associated investigation and recommendations
for improvement.
- Preventable describes an event that could have been anticipated
and prepared against, but that occurs because of an error or another
system failure.
- Root cause analysis is a method used to investigate and analyse a
serious or sentinel event to identify cause and contributing factors
and to recommend actions to prevent a similar occurrence.
- Medication errors are a common category of adverse event. The
following diagram is an example of how a medication error can be
classified and recorded based on the circumstances and outcome.
The process for reviewing serious events
Waikato DHB introduced processes for reviewing serious events, using Root Cause Analysis.
The process involves discussions held with staff involved in the event, following which the root causes and other learnings are identified by a member of the Quality and Risk Service in consultation with the staff involved.
An action plan is developed - again in consultation with the staff involved to ensure that the proposed actions will assist in preventing recurrence of a similar event. The Serious Event Panel, chaired by the chief medical advisor and including senior medical, nursing, quality and risk staff and managers, meets to review the Root Cause Analysis and the Action Plan to make any amendments and approve them.
The Mental Health Service has its own Serious Event Panel to review Mental Health Services events.
The Quality and Risk Service maintains a central record of all incidents and serious and sentinel events and provides quarterly reports to the Clinical Board which monitors achievements of the agreed actions.
Where the information provided in the Event Tables released to the media is missing, this means that documented evidence of the implementation of these actions has not been received by the Quality and Risk Service.
The actions may have been taken, but are not signed off until documentary evidence has been received.
Twenty four serious and sentinel events from 2006-2007 representing 0.027 per cent of discharges (86,185), were reviewed.
That, compared with the national figure for all DHBs of 0.022 per cent, means that Waikato DHB has slightly higher reporting levels but is similar to other DHBs in that this figure is approximately 10 times less than the figure quoted in the Peter Davis study. The Davis study found that 0.2 per cent of patient admissions resulted in a preventable adverse event.
Waikato DHB Serious and Sentinel Event responses
2008/20092006/20072005/20062004/20052003/2004Further information
Waikato DHB Procedure for Serious and Sentinel Event Review
Health Waikato Where to Now: Quality and Safety
Health Waikato Leadership Walk Rounds
Safety Improvement Programme Newsletter - May 2008
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