The purpose of recording and investigating preventable adverse events in hospitals is to understand why these events occurred, which then provides a basis for taking action to try to prevent similar events from happening in the future. The overall aim is to improve patient safety.
In February 2008 the Quality Improvement Committee released the first sentinel and serious events report. Although hospitals have always collected data about such incidents, this report for 2006/07 represented the first consolidated report about serious and sentinel events across New Zealand’s 21 DHBs. The release of this data is an important part of a national reporting system. It does not capture every event, but through initiatives to encourage open disclosure and learning, and with improved definitions, we will see the development of a culture of reporting events.
The purpose of the reporting system is to learn from incidents, not to apportion blame or to rank hospitals. Clinical staff have always been accountable for their practice to their patients, their profession, their colleagues and the organisations that employ them. The health sector must use this data in a way that encourages learning. Using it in any other way would adversely affect the culture of safety and openness we are trying to foster in DHBs. If clinicians believe that the information would be used against them or their DHB, they may be less willing to report such 9
events. If clinicians believe the information will be used for learning and improvement, they will more readily report adverse events.
International experience with event reporting shows that the process of increasing awareness often results in a rise in the number of events reported. For this reason, the number of events reported nationally may well continue to rise over the next few years.