NZMA Welcomes Serious And Sentinel Events Report To Reduce Future Harm

The NZMA welcomes the release today of the Health Quality and Safety Commission’s (HQSC) 2010/2011 serious and sentinel events report, which will help the New Zealand health sector to work towards reducing harm from preventable adverse incidents.

NZMA Chair Dr Paul Ockelford said that the report, which outlines 377 cases of serious and sentinel events reported in the past year, will help to enhance patient safety.

“The reporting of events provides transparency to enable our health sector to address systemic issues that may have contributed to a patient’s death or severe injury. Many should not have happened and we must learn from them to prevent future patients from being harmed by the same mistakes."

The total number of serious and sentinel events has risen from the previous year, mainly due to an increased number of falls being reported (195, up from 130). The report said possible explanations are the admission of more elderly patients, with increasingly complex illnesses, and altered reporting criteria.  Clinical management events such as errors of diagnosis and treatment were the next largest category of incidents, followed by medication errors.

Dr Ockelford said it was pleasing that the HQSC was working closely with DHBs and the wider health and disability sector to make improvements, including the development of more consistent reporting strategies amongst DHBs, and the development of education and training to support serious incident review and open disclosure.

Initiatives in place to help reduce preventable adverse incidents, such as the Safe Surgical Checklist and a National Medication Chart, are quality improvements.

Dr Ockelford said that while it is essential that we learn from these incidents to improve patient safety, it is important for the public to recognise that the events in the report represented a small fraction of the total number of patients cared for within our hospitals.

“By international standards New Zealand has an excellent health system. The vast majority of patients receive high levels of care.”

The NZMA agreed with the report’s recommendation that there were advantages in patients taking a greater role in determining and contributing to their own care.

“This is one of the principles in the Role of the Doctor consensus statement which was developed by the medical profession recently – the need for the doctor, and other health professionals, to support patients in understanding their condition and empowering them to make informed decisions. In future we anticipate greater moves towards self-care within the healthcare team.”