Serious and Sentinel Events Report – Making Our Hospitals Safer

20 Feburary 2012

A total of 377 serious and sentinel events occurred in New Zealand’s public hospitals in 2010/2011 – a rate of more than one for every day of the year.

The Health Quality & Safety Commission says some people died and many suffered serious injury or disability as a result of these events, and it’s calling on health providers and those working in health and disability services to learn from the mistakes of the past.

“The people involved in these 377 events were let down by the system that exists to protect them,” says Professor Alan Merry, the Commission’s Chair.

“We should view these events through the eyes of patients and their families, and acknowledge that many of them should never have happened.”

The Commission has released the 2010/2011 report of serious and sentinel events in the country’s District Health Boards (DHBs). A serious or sentinel event has, or has the potential to result in, serious lasting disability or death not related to the natural course of the patient’s illness or underlying condition.

Of the 377 events reported, 86 patients died, although not necessarily as a result of the adverse event which occurred.

Professor Merry says New Zealand has an excellent health and disability system, with more than 2.7 million people treated in public hospitals or as outpatients each year and very few occasions of serious harm.

“The fact remains, however, that a small number of people are injured in the course of receiving treatment and an even smaller number lose their lives as a result of something that happens to them in hospital.

“It’s not about apportioning blame – it’s about improving the quality and safety of our health and disability services.”

The Commission took over responsibility for collating information and reporting on serious and sentinel events when it was established in 2010. This report is the Commission’s second, and the fifth by DHBs. It does not capture all adverse events that occurred in public hospitals, only those considered by each DHB as serious or sentinel events.

According to the figures, 195 falls were reported as serious and sentinel events in 2010/11, up from 130 falls reported for the previous year. A total of 25 medication errors were reported, along with 108 clinical management incidents which included:

  • delays in responding to a patient’s changing or deteriorating condition
  • poor communication between health professionals
  • delayed diagnoses due to failings in referral processes and the reporting of results.

Outpatient suicides have not been included in this report, unlike previous years, as the Commission is of the view that these events are very different from the other events reported. The Commission will be working with the mental health sector over the next year to find better ways of reporting and reducing suicides.

Professor Merry says the high number of falls is of particular concern and the Commission is working closely with the sector to prevent and reduce harm from falls. It is also working on initiatives to reduce medication errors and health care associated infections, promote use of the World Health Organization’s safe surgery checklist, and to improve the quality of data and reporting of adverse events.

“The Commission’s role is to improve quality and safety in New Zealand’s health and disability sectors, and a key aspect of that is to reduce harm from preventable errors. While some adverse events are outside our control and will always occur, there are many other preventable incidents which we should aim to erase completely.”

He says some DHB Boards are now regularly reporting adverse events during open meetings, and he applauds their transparency.

Professor Merry urges health professionals to familiarise themselves with the report’s findings and to look at how they can make the services they provide safer for patients.

“It’s not acceptable to keep making preventable errors and all of us who work in health need to redouble our efforts to ensure patients receive the best and safest care,” he says.

A full copy of the report is available on the Commission’s website at

For more information visit the Health Quality & Safety Commission’s website at or contact Cushla Managh on 021 800 507 or by email:

A serious adverse event requires significant additional treatment but is not life threatening and has not resulted in a major loss of function.
A sentinel adverse event is life threatening, or has led to an unanticipated death or major loss of function.
Note: some of the adverse events included in this serious and sentinel events report are subject to further review, and numbers may change.

Last updated: Tuesday, February 21, 2012

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