Main Navigation Links
C&C DHB Serious and Sentinel Events
The following comments are from C&C DHB Chief Executive, Dr Derek Milne:
“The nationwide release of serious and sentinel event reports by the Quality Improvement Committee of the Ministry of Health is an important initiative which Capital & Coast DHB is pleased to participate in.
“It is unfortunate that at this point in time there is no consistent national approach to recording serious and sentinel events. DHBs use different definitions and criteria by which to decide what is a serious or sentinel event, and accordingly which events they report on. We would welcome the move to a consistent system, which in future years would allow more meaningful comparisons to be made than can be made in this initial release.
“C&C DHB always takes incidents seriously and has put in place a careful system for ensuring investigations are carried out and changes made to procedures and policies where necessary, to avoid a recurrence.
“C&C DHB has been diligent in reporting on events, and has strongly encouraged all staff to bring any issues, incidents or problems to the attention of our Quality Improvement Unit by filing reportable events forms. Staff have really got behind us on this, and we believe the data we have compiled for the Ministry of Health’s release gives a very thorough and accurate account.
“As the Ministry of Health and others have pointed out, it is a national and international reality of medicine that sometimes things do go wrong. Acknowledging and learning from those incidents enables hospitals to reduce the incidence rate of events, and to mitigate any adverse outcomes when errors do occur.
“It is important for the public to realise that the number of events does not necessarily relate to whether patients are “less” or “more” safe at any given hospital. In fact, given the lack of a consistent nationwide reporting system, a higher number at any given DHB is more likely to mean that there is a robust reporting system in place, errors are picked up and learned from, and patient safety is improved because of it.
“The Ministry assures me that, based on other indicators of the relative safety of hospitals, Wellington Hospital is on a par with, and in numerous respects ahead of, other tertiary hospitals in New Zealand in terms of safety.
“It is also useful to put the number of incidents in context. Over the period July 2006 – June 2007, C&C DHB had over 46,818 hospital discharges, in addition to the many tens of thousands of interactions with outpatients and patients in the community.
“While this does not diminish the seriousness of these events and their impact on the patients and families concerned, the overwhelming majority of patients who use our services receive outstanding care with excellent outcomes.
“Serious and sentinel events resulting in patient harm are always deeply regrettable and can have a profound impact on patients, their families, and on staff who do their very best to care for them.
“We acknowledge the impact of these events and apologise for any distress to the patients and their families involved in these events.
“Our determination to ensure safe, high quality, continuous and responsive patient care is constant and our staff are committed to continuously improving these systems and procedures.
“Our top priority has always been the safety and appropriate care of our patients and we will continue to provide the very best services we can.”
Footer Links
