Serious and Sentinel Events
back to previous page
What are Serious and Sentinel Events?More than 2.7 million people are treated in public hospitals or as outpatients each year, and harm to patients is rare.
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.
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 Health Quality & Safety Commission is leading this standardisation work in New Zealand.
Media releases2012
2011
2010
2009
2008
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 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
Serious and sentinel event reportingThe 52 serious and sentinel incidents in 2010-2011 comprised
- 24 falls (seven deaths)
- 19 clinical management problems (nine deaths)
- five 'other' (two deaths)
- two wrong patient events
- one delay in transfer (death)
- one retained instrument or swab
- The 52 events represented 0.061 per cent or 6.1 in every 10,000 total admissions.
- There were 3 sentinel and 49 serious events.
For more information visit National Reportable Events Policy Offers Guidance
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
back to top
|
