Kupu Taurangi Hauora o Aotearoa

1. November 2010 Kupu Taurangi Hauora o Aotearoa

2. Making Our Hospitals Safer Serious and Sentinel Events 2009/2010 Report released 17 November, 2010

3. New Zealand has an excellent health system • However, for a small number of people events happen that: • cause harm, or • have the potential to cause harm

4. 76-year-old woman • In hospital recovering well from a chest infection • Assessed as a risk for falls, should mobilise only with staff assistance • Rang buzzer - no response • Got out of bed, slipped on a wet floor, fractured hip • Needed surgery and longer hospital stay

5. 25-year-old woman • Assessed for planned eye surgery • Follow-up appointment notification not sent • Surgery delayed • Considerable additional eye damage

6. DHBs report each year • Serious adverse event • requires significant additional treatment, but is not life threatening, no major loss of function • Sentinel adverse event • life threatening, or led to death or major loss of function

7. These events are: • traumatic • often tragic • distressing • costly for the health care system • Onus is on all of us to learn from them

8. 2009/2010 year • 374 people in serious or sentinel event • 127 died during admission or shortly afterwards • 64 of these deaths were through suicide

9. Over same period • Nearly 1 million people treated and discharged • 1.7 million outpatient discharges

10. Sentinel or Serious Events, by DHB, 2007 to 2010*

11. Most common events 2009/2010 • Falls 34% • Clinical management problems 33% • Suicide 17%

12. Percentage of All Event Types Retained instruments/swabs Assault on patient Wrong patient, site, procedure Suicide Clinical Management problems Other Hospital-acquired infection AWOL patient Falls Medication error

13. Classification of Serious and Sentinel Events in the Clinical Management Category 2009/10

14. Pie graph of percentage of events associated with the death of a patient Percentage of Events Associated with Death of a Patient Falls Other Hospital-acquired infection Medication error Clinical management problems Suicide

15. Factors contributing to events • Failure to recognise clinical deterioration • Medication errors • Poor communication

16. Factors contributing to events • Failures in referral and recall processes • Inadequate staff knowledge • Inappropriate staff mix on acute wards

17. Initiatives in response to reporting • Most DHBs adopted WHO’s Safe Surgery checklist • Many DHBs have strong falls prevention programmes

18. Initiatives in response to reporting • Improvements in clinical management (eg, early warning systems) • Improved booking and referral processes • Standardised process to reconcile medicines and reduce medicine handover errors planned

19. Continued focus on safety essential • We need to learn from events to continue to improve safety in our hospitals • Every health care worker is urged to read the full report – www.hqsc.govt.nz • Feedback encouraged – info@hqsc.govt.nz Thank you

20. November 2010 Kupu Taurangi Hauora o Aotearoa