Sentinel Event Annual Report 200203

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Sentinel Event Annual Report 2002-03
Dr Jenny Bartlett Chief Clinical Advisor
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Overview

• REPORT
• Background to the report
• Findings to date
• How were the system issues managed?
• Recommendations
• WORKSHOP
• Issues for discussion
• Outcomes for today

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Background

• Sentinel Event Program introduced July 2001 as
  part of Clinical Risk Management Strategy
• In 2002-03, 79 sentinel events were reported and
  analysed
• First Sentinel Event Public Report 2002-03
• Workshop Where to from here?

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Findings

• 79 events were analysed
• Procedure involving wrong patient or body
  part 16
• Suicide in an inpatient unit 5
• Retained instruments or other material after
  surgery requiring
• re-operation or further surgical procedure
  9
• Intravascular gas embolism resulting in death or
  neurological
• damage 0
• Haemolytic blood transfusion reaction resulting
  from ABO
• in-compatibility 0
• Medication error leading to the death of patient
  reasonably believed
• to be due to incorrect administration of
  drugs 3
• Maternal death or serious morbidity associated
  with labour or delivery 4
• Infant discharged to wrong family 0
• Other catastrophic event 42

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Findings

• Other catastrophic event types
• Complication or emergency / resuscitation
  management 9
• Complication of surgery 9
• Foetal complication of delivery 3
• Complication of inpatient fall 2
• Patient absconding from inpatient unit with
  adverse outcome 2
• Infection control breach Hospital process issue
  9
• Other unspecified 2
• TOTAL 42

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Issues

• Current reporting framework
• Data analysis and contributing factors
• System to analyse events which occur across
  organisation
• Review of the sentinel event list
• Inclusion of Near Miss sentinel events
• Education required in root cause analysis

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Contributing Factors

• 23 types of system factors
• Communication
• Human resources
• Procedures/guidelines
• Health Information
• Equipment
• Physical Environment
• External factors
• P

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The system issues

• Risk Reduction Action Plans (RRAP)
• Assessment of RRAP to determine if issue relevant
  to other organisations
• Expert advice requested
• Recommendations for the health service
• The Department feedback individual health
  services
• Risk Watch newsletter

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Recommendations

• Just the beginning
• Education
• Multi-service RCA system
• Inclusion of Near Miss events
• Timeliness of RCA and RRAP
• Review of sentinel event reporting list

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Contributing Issues

• Open disclosure standard
• Sentinel event list
• Health Ministers Directive of April 2004
• Qualified Privilege

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Workshop communication

• Clinical Risk Management Reference Group
• CRM website
• RCA Education program 2004-05
• Open disclosure standard rollout 2004-05

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Questions