Making Our Hospitals Safer

20 February 2012

Making Our Hospitals Safer

The reporting today of Sentinel and Serious Events by the Health Quality and Safety Commission sharpens the focus on the quality of patient care at the West Coast DHB says Chief Medical Officer Dr Carol Atmore.

The Health Quality and Safety Commission New Zealand report “Making Our Hospitals safer” was released today. This report can be accessed via their website www.hqsc.govt.nz.

“The West Coast DHB sincerely regrets any errors that have resulted in any harm happening to patients in its care,” said Dr Atmore. “It is unfortunate for everyone in the public health system when there is the loss of life or a patient suffers a permanent serious injury when receiving medical care. For patients, families and staff this is a traumatic time that everyone is determined not to see repeated.”

The incident reporting and investigating process is the backbone of determining the cause of an incident, or near-miss and reducing the likelihood of it ever recurring.

The West Coast DHB’s system has four key parts. The recognising and reporting of incidents and near-misses is first stage. A growing culture of transparency within the DHB leads to staff being willing to freely report incidents in an atmosphere of openness and trust.

Incidents are then investigated, by a team if they are serious. Most incidents or near misses are found to be not the result of one unsafe act, but often a chain of events and circumstances that that create unexpected gaps in the process of caring for patients.

The investigation is then reviewed by a multi-perspective team. The review team has the responsibility to recognise examples of excellence that occurred around the incident and to identify any gaps in systems or procedures. From that recommendations are made with the intention of reducing the likelihood of something similar happening again.

Finally key staff are tasked with implementing and monitoring the recommendations of the review group.

Serious incidents are also reported to and monitored by the Health Quality and Safety Commission. It is their decision as to which events are reported publically as part of their annual report.

“The reporting system on the West Coast underpins the organisation’s quality and assurance processes. West Coasters can be assured that the reporting and investigation processes that occur, serve to make our hospitals safer and lessen the chance of future incidents,” said David Meates, West Coast DHB Chief Executive.

Background information and frequently-asked questions

How many serious and sentinel events were reported by West Coat District Health Board (WCDHB)?

The Health Quality & Safety Commission report lists five events for WCDHB, however, it’s important to note that subsequent to printing their report, one incident was subsequently determined to be a death due to natural causes.

There was a late addition to the report which is not detailed in their online break-down of events. This is an issue regarding malfunctioning anaesthetic machines. This has been reported as a serious event despite no harm occurring to any patients.

With one addition and one incident removed, the total number of events remains at five.

What is an adverse event?

An adverse event is a health care event causing patient harm that is not related to the natural course of a patient’s illness or underlying condition.

A serious adverse event requires 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.

Preventable describes an event that could have been anticipated and prepared for, but that occurs because of an error or some other system failure.

ENDS

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