The annual serious and sentinel events (SSEs) report, released by safety watchdog, the Health Quality & Safety Commission, this week shows that treatment delays and patient suicides are on the rise but falls and medication errors are decreasing.
Key findings
360 SSEs were reported, down 3 per cent from the 370 recorded in 2010/11. Ninety-one patients died (up from 86 in 2010/11), although not necessarily as a result of the adverse event that affected them.
Key adverse events recorded include:
- 170 falls (down 13 per cent from the 195 reported falls last year) – and the first decrease since reporting began.
- 111 clinical management events (up from 105 in 2010/11). This includes 17 cases of delayed treatment due to "failures in hospital systems".
- 18 medication errors (down from 25 the previous year).
- 17 suspected in-patient suicides (up from 3 the previous year).
- 6 mental health patients missing from in-patient facilities (an increasing trend, up from 4 last year and 3 the year before).
Of the individual DHBs, Waikato DHB was the big improver, with 26 SSEs compared to 52 in the previous year. MidCentral DHB went from 22 SSEs last year to 15 this year, Counties Manukau dropped from 35 to 24 SSEs, and Southern DHB reduced their SSEs from 40 to 30.
Auckland DHB reported 62 SSEs (up from 54 last year), which was the highest number of SSES reported. Canterbury DHB stayed constant in the past 12 months with 49 SSEs.
Reporting SSEs is always an issue that casts a shadow across these results. For example, Taranaki DHB rose from 3 to 18 SSES in the past 12 months, but prior to this year, the DHB only reported SAC 1 and 2 events that were considered preventable.
Trends
While Commission chair Prof Alan Merry acknowledged that many involved errors that should not have happened, he praised DHBs' efforts in falls prevention.
“This is very good news and represents a lot of hard work by DHBs to both report and prevent adverse events,” he said. “At the same time, we have seen an increase in the number of cases of delayed treatment and suspected in-patient suicides.”
The Commission said it was probable the number of reported delays represented just a small fraction of all cases because many fell below the reporting threshold.
Prof Merry said the greater number of suspected in-patient suicides this year does not appear to be part of an increasing trend (with 3 suicides last year, 4 in 2009/10, and 8 in 2008/09). Most of the cases involved mental health patients, although at least two were patients who had been on general wards.
The Commission’s reportable events clinical lead, Dr David Sage, said the cases involving delays emphasise two things – how important it is for clinicians to follow up when tests have been ordered, referrals made, or further treatment recommended and the importance of formal reconciliation procedures when organising biopsies and appointments.
“The Commission is looking at measures that can be put in place to reduce the likelihood of these types of events. For example, making sure patients are full partners in the management of their care – so they too are aware if there needs to be a further test, result from a specimen, or referral to another specialist,” he said.
The report can be downloaded from here.
