Serious and Sentinel Events

What are Serious and Sentinel Events?

Every year in New Zealand, more than 998,00 people are 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.

Waikato DHB reports annually on these potentially preventable serious and sentinel adverse events. A serious adverse event is one that requires significant additional treatment, but is not life threatening and has not resulted in a major loss of function. A sentinel adverse event is life threatening or had led to an unanticipated death or major loss of function.

Tom Watson
Chief Medical Advisor

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 our 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.

Media releases

2010

2009

2008

Waikato focussed on quality and safety

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 process for reviewing serious events

Sue Hayward
Director of
Nursing & Midwifery

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.

Waikato DHB Serious and Sentinel Event responses

2009/2010
2008/2009
2006/2007
2005/2006
2004/2005
2003/2004

Serious and sentinel event reporting

Category	Waikato	Mental Health	Other	Total
Inpatients	41059	1364	7069	49492
Daypatients	29079	284	6591	35954
Total	70138	1648	13660	85446
Outpatients	187706	0	26558	214264

The 52 serious and sentinel incidents comprised:

13 falls
25 clinical management problems
one 'other'
three hospital acquired infections
one medication error
one retained instrument or swab
eight Mental Health events of which there were:

three suicides
one absent without leave
four 'others'.

The 52 events represented 0.061 per cent or 6.1 in every 10,000 total admissions.
There were 21 sentinel and 31 serious events.

Jan Adams
Chief Operating Officer
Health Waikato

For more information visit the Ministry of Health website.

A Serious event has the potential to result in death or major loss of function, not related to the natural course of the patient’s illness or underlying condition.

A Sentinel event has resulted in an unanticipated death or major loss of function not related to the course of the patient’s illness or underlying condition.

The Severity Assessment Code (SAC) is the method used by any person who has identified an incident, to determine the appropriate action to take on that incident.

The score is ascertained by rating the consequence of the incident and its likelihood of occurrence. Read more.

Further information

MoH Serious and Sentinel Events
Waikato DHB Procedure for Serious and Sentinel Event Review
Health Waikato Leadership Walk Rounds
Safety Improvement Programme Newsletter - May 2008

About Waikato DHB
Quality Improvement Committee (Serious and Sentinel events)