Serious & sentinel (adverse) events for 2013/2014

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 (adverse) 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 (adverse) 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 FY 2013/2014 serious and sentinel event report was the sixth year of reporting:

Financial Year

Total # of serious & sentinel events

Events related to falls resulting in major harm

2008/2009

20

2

2009/2010

17

9

2010/2011

29

19

2011/2012

29

13

Improvements made to our reporting systems

2012/2013

50

37

2013/2014

48

39


Waitemata DHB serious & sentinel events report for 2013/2014

Waitemata DHB’s FY 2013/2014 national serious and sentinel event report for 2013/2014 can be found here - [view our serious & sentinel events report for 2013/2014 ].


Summary of falls causing patient harm 2013/2014

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 and 39 for FY 2013/2014. 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.

For the 39 falls resulting in serious harm:

  • 16 were fractures of the hip
  • 8 were fractures of the upper limb
  • 3 were fractures of the pelvis
  • 4 were head injuries
  • 2 were fractured noses

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 and members of the quality team. [View more about our Falls prevention programme Part I and Part II].

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

  • making sure patients aged 75 years and over (55 years 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

Falls prevention 2013/2014

The charge nurse managers have worked with the associate director of nursing to improve our falls audit system, including increasing the frequency of audits, creating a falls audit database with electronic reporting software to speed up the analysis and reporting of results (see falls audit results below) ,and improving the way audit results are displayed on quality boards.

Falls audit results
Falls audit results

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.

Falls champions forums

Phase Two of a Falls Prevention Programme has been completed. This phase of the programme focused on reducing the risk of falls with serious harm. Key interventions included the redesign of the falls risk assessment and care plan and its implementation, and the design and implementation of a post fall checklist to be completed by the nurse immediately post a fall. The aim of the checklist is to identify specific issues which need to be addressed to prevent further falls, and to improve the quality of investigation of falls. Wards are using a Falls Safety Cross to raise awareness of falls frequency.

The Falls Prevention programme has moved from a quality improvement programme to business as usual, with phase three of the programme focusing on a number of key areas, including:

  • Ward discussions – the Heads of Division Nursing regularly meet with ward fall champions and other ward staff to discuss ward falls data, particular ward issues , what is working well on other wards, and lessons from falls investigations.
  • Quality study days - these are held every three months for ward quality representatives and Falls is part of the regular agenda for discussion and learning.
  • Falls Champions days – falls champions have been identified on every ward and regular education and training days are held for the champions. Topics discussed at the training days include falls data for the DHB and for each ward and what it is telling us about falls (e.g. where falls are occurring; what time of day falls occur; what type of harm is resulting from falls etc); themes identified from serious and sentinel event investigations; falls prevention measures, observation of patients; handover from ward to ward; and timely and complete risk assessment and care planning. The champions have also participated in regional First Do No Harm workshops on falls prevention.
  • Improving investigations – the role of the charge nurse manager in the initial stage of investigating a fall has been reinforced and the investigation report has been revised to ensure that the investigation identifies recommendations that will help prevent future falls with harm.
  • A schedule of weekly auditing of falls risk assessments and care planning, which commenced in August 2013. There has been significant improvement in the national Health Quality and Safety Falls Markers (the per cent of at risk patients assessed for risk of falls; and the per cent of patients medium or high risk for falling with an individualised care plan), since the introduction of this weekly audit. The audit results are now available electronically in real time for senior nurses to monitor and report to ward staff, and to patients and their families via ward quality boards.