The New Zealand public health system has published its second annual report on learning from ‘serious and sentinel’ events in its hospitals. Produced by the Quality Improvement Committee, this report, based on 2007/08 data, identifies contributing factors and actions related to root cause analysis of incidents. In this regard, the report, sadly, reminds us of the National Patient Safety Agency’s ongoing inability to provide the NHS with information for learning based on root cause analysis, despite this being the fundamental principle on which the Agency was launched nearly 8 years ago!
In New Zealand, during 2007/08, approximately 0.03% (3 in ten thousand) of total admissions to hospitals were reported as involving a potentially preventable serious or sentinel event.
The majority of events (42%) were the result of a clinical management problem. These are events where there is a serious deterioration in a patient’s condition that is not due to the natural course of their illness, or differs from the expected outcome of treatment. Using root cause analysis techniques, the the underlying causes and any contributing factors and recommending actions to reduce the chance of a similar occurrence were identified. In the events reported that involved the clinical management during 2007/08, such actions included:
– changes to patient monitoring and care delivery processes
– changes to the physical environment
– increased supervision of staff
– staff education
– development of new policies, protocols or guidelines
– purchase of new equipment.
The second largest category of events comprised falls (23%). The majority of events in this category were falls that occurred when the patient was medically unwell and/or when an elderly patient was mobilising without assistance.
For reducing the numbers of such falls, recommended actions included:
– improving the use of falls risk tools to assess the patient’s risk of falling, as well as the use of care plans
– implementing hourly nursing rounds to anticipate toileting and other needs
– educating staff on falls prevention and management policy in this area
– maintaining equipment.
The third largest category of events reported in 2007/08 was medication errors (8%). Over half of the medication errors were either overdoses or wrong doses. In many cases issues such as the similarity of packaging for different doses of the same medication contributed to the error occurring.
To reduce medication errors, the recommended actions include adopting more rigorous checking procedures and investigating the feasibility of using technology that may assist in reducing these errors.
In the other event categories, strategies to improve care and prevent similar events happening in the future included:
– improving assessment of patients at risk
– increasing supervision of staff
– educating to increase the level of knowledge of clinical staff
– reviewing physical risk areas and reconfiguring clinical areas
– improving communication between hospital teams and with families
The full report can be freely downloaded here.