Serious and Sentinel Events Report 2011

Nine patients suffered serious harm unrelated to their planned treatment during their stay in Wanganui Hospital last year – the same number of serious and sentinel events recorded by the Whanganui District Health Board (WDHB) in 2010.
WDHB director of nursing, patient safety and quality Sandy Blake said today it was important to acknowledge that the harm suffered is often devastating for patients and their families and increases the time spent in hospital.
“Injuries sustained through serious and sentinel events have the potential to result in permanent disability, loss of function or death,” Mrs Blake said.
“An example of what can happen is a patient, who having been admitted to hospital to have their gall bladder removed, trips on the way to the bathroom, breaks their hip and is operated on to repair the hip in addition to their gall bladder operation.”
Mrs Blake is confident that the WDHB has a robust reporting system in place and that the information passed onto the Ministry of Health is a true reflection of accidents that have occurred at Wanganui Hospital.
“ We have worked very hard to establish a climate in which staff are encouraged to report incidents and near misses, make sure that lessons are learnt from the adverse events and to give the community ongoing confidence that patient safety is paramount to our  hospital,” Mrs Blake said.
“Wanganui Hospital staff are very open with patients, their family and friends about the causes of the adverse event and the steps taken to reduce further events. Clinicians involved in the care of the patient often feel guilt, sadness and sorrow for the harm that has occurred.”
The serious and sentinel events recorded by the WDHB were:
  • a patient falling and dying as a result of injuries sustained
  • a 15-month delay in diagnosing lung cancer for a patient who died several months later
  • a patient admitted and sedated for the extraction of a tooth which had previously been removed
  • a patient becoming unconscious after being given the wrong medication
  • failure to make an outpatient appointment which resulted in delayed treatment
  • one  patient fall which resulted in fractured hips
  • temporary paralysis and patient trauma resulting from medication being given in the incorrect order
  • delayed response to a patient’s deteriorating condition which led to their requiring further extensive surgery.
A sentinel event is any unanticipated event in a healthcare setting which results in death or serious physical or psychological injury to a patient or patients, and which is not related to the original natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures. The Joint Commission tracks events in a database to ensure events are adequately analysed and undesirable trends or decreases in performance are caught early and mitigated.