Serious and Sentinel Events for 2012/2013

What is a serious or sentinel event?

A serious or sentinel event is an adverse event which has generally resulted in harm to patients not related to the natural course of the patient’s illness or underlying condition.  A serious event is one which has led to significant additional treatment and a sentinel event is life threatening or has led to an unexpected death or major loss of function.

As part of Waitemata DHB’s commitment to providing safe care for patients, we have a process in place for investigating serious and sentinel events that occur in our hospitals.  The purpose of investigating serious and sentinel events is to determine the underlying causes of the event so that improvements can be made to the systems of care to reduce the likelihood of such events occurring again.

Serious & sentinel events reporting

Serious and sentinel events must be reported to the Health Quality and Safety Commission (HQSC) so that lessons can be shared about how to prevent similar events in the future.

The serious and sentinel event reports also inform the Commission’s and DHBs’ quality and safety programmes.

The Health Quality and Safety Commission produces a national report on serious and sentinel events each year, based on information provided by DHBs [view national reports on HQSC website].  Each DHB produces a report providing further detail on its serious and sentinel events for that reporting year.

The Financial Year (FY) 2011/2012 national serious and sentinel event report[1], highlighted the importance of continuing the work to reduce the rate of falls in hospitals and the need for the sector to focus on delays in treatment due to breakdowns in hospital systems. Waitemata DHB’s serious and sentinel event report for FY 2011/2012 identified a total of 28 events, 13 of which were due to falls.

  1. Making our hospitals safer. Health Quality and Safety Commission, Nov 2012

Waitemata DHB serious & sentinel events report for 2012/2013

In FY 2012/2013 Waitemata DHB reported a total of 50 serious and sentinel events.  The increase in the number of serious and sentinel events from 28 (2011/2012) to 50 (2012/2013) reflects improvements we have made to our reporting system [view our serious and sentinel events report for 2012/2013].

Summary of falls causing patient harm 2012/2013

Falls resulting in serious harm are the most common serious and sentinel event and account for the increase in the total number of serious and sentinel events from 2011/2012 to 2012/2013. The total number of falls resulting in serious harm has increased almost three-fold, from 13 events in 2011/2012 to 37 in 2012/2013. This increase reflects improvements we have made to our reporting and checking systems, including raised awareness of the importance of reporting falls by our staff, and ensuring we accurately record all injuries that occur as a result of a fall.

The increase in the number of serious and sentinel event falls is due to improved reporting and checking of these events rather than more people falling, because the rate of falls occurring in our hospitals(number of falls per 1000 patients) has not increased significantly .

The improvements to our reporting system include a review of all falls that were reported in 2012/2013 to check that they were correctly classified. The team identified 19 falls which resulted in more serious harm than originally reported, e.g. when the harm resulting from a fall appears less serious at the time the fall is reported and later a fracture is identified on an X-ray.  As a result these falls were subsequently reclassified as serious and sentinel events. 

For the 37 falls resulting in serious harm:

  • there were 16 fractures of the hip
  • there were 7 fractures of the upper limb
  • there were 6 fractures of the pelvis
  • 1 patient suffered a head injury.

Preventing falls is a key focus of Waitemata DHB’s patient safety programme.  A multidisciplinary group is overseeing a falls prevention programme, which is led by the Associate Director of Nursing, and is supported by senior nurse leaders, a quality improvement specialist, and members of the quality team [view more about our Falls prevention programme and Falls prevention II: zero falls with harm]

Current strategies in place to reduce the risk of serious harm from a fall include:

  • making sure patients aged 75 yrs and over (55yrs and over for Maori and Pacific patients) have a falls risk assessment completed within 8 hours of admission to hospital
  • ensuring appropriate interventions are put in place according to the assessed risk, including:
    • placing a falls alert sticker in the patient’s notes
    • placing a falls magnet beside the patient’s name on the ward’s whiteboard
    • medication reviews by our pharmacists to avoid the use of medications that can increase the risk of falling
    • hourly rounding by nurses to check their patients
    • using a low bed
    • using falls monitors which alarm when a patient moves to get out of bed
    • using walking frames and other supports
    • providing patients with non-slip socks
    • ensuring every patient’s falls risk is reassessed regularly or when their condition changes

Plans for falls prevention 2013/2014

The charge nurse managers are working with the Associate Director of Nursing to improve our falls audit system, including increasing the frequency of audits, creating a falls audit data base to speed up the reporting and analysis of results , and enhancing the way audit results are displayed on quality boards.

The charge nurse managers are taking a key leadership role in monitoring falls prevention on the wards, investigating all falls and identifying things we can do to stop falls from happening in the future, and educating other staff, patients and their families about the importance of falls prevention and what they can do to help.

We are focusing on making sure we consistently apply our falls prevention measures - by consistently assessing falls risk and consistently applying falls prevention measures when they are needed.

In addition, Waitemata DHB’s quality team has looked in more detail at the serious and sentinel event falls cases to try and identify where, when and why patients are falling and suffering significant harm, and what happens to patient after a fall.  This falls analysis report  will be used to inform quality improvement efforts [view our falls with major harm 2012/2013 analysis report].

Our analysis confirms that:

  • age is the most significant risk factor for patients falling in our hospitals (the average age of patients falling and suffering major harm is 83.51yrs (88.24yrs for patients whose falls result in hip)
  • the majority of falls are happening at the patient’s bedside, i.e. when the patient gets up and out of bed
  • the impact of a fall in hospital resulting in major harm is particularly significant with only one third of patients being able to return home following their admission

The analysis reinforces the importance of the work we are doing to try and prevent falls from happening in our hospitals.