All DHBs across the country are required to report annually on 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.
Standardised, consistent systems for classifying and recording adverse events are essential to this process. The Health Quality & Safety Commission is leading this standardisation work in New Zealand.
More information can be found on the Health Quality & Safety Commission New Zealand’s ‘Learning from adverse events reports’ web section.
The West Coast DHB’s incident investigation system has four essential elements. Recognising and reporting incidents and near-misses is the first stage. A ‘no blame’ culture leads to staff being willing to report incidents in an atmosphere of openness and trust.
Incidents are then investigated with recommendations made to address any system gaps identified. Most adverse events or near misses are the result of a chain of events and circumstances that create unexpected gaps in the process of caring for patients.
The investigation is then reviewed by a multi-disciplinary team. From that review, further recommendations might be made, also with the intention of reducing the likelihood of something similar happening again.
Finally, key staff are tasked with implementing and monitoring the recommendations to ensure real change occurs.
Serious incidents are also reported to and monitored by the Health Quality and Safety Commission.
These events were previously referred to as ‘serious and sentinel’ events.
An adverse event is any event not related to the natural course of a patient’s illness or underlying condition that has resulted in harm to a patient.
A Severity Assessment Code (SAC) Matrix is used to help ensure that the appropriate level of investigation is undertaken. Depending on the outcome of the event a code of 1-4 is assigned. The code determines the level and depth of investigation that occurs. Any incident scoring 1 or 2 is deemed to be serious and is notified to the Health Quality and Safety Commission. An example of this includes a patient who has a fall while in hospital and breaks a bone.
Page last updated: 6 May 2019
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