Waikato DHB’s chief medical advisor says the 52 serious and sentinel events reported by the DHB to the Health Quality and Safety Commission in the year ended 30 June shows patient safety is a priority in the organisation.
Dr Tom Watson said the 21 sentinel and 31 serious events were traumatic for patients, families and our staff. During the 2009 /2010 year Waikato DHB’s provider arm, Health Waikato treated and discharged nearly 85,446 patients. There were also 214,264 outpatient discharges.
“To put the 52 events into perspective, it represented 0.061 per cent or 6.1 in every 10,000 total admissions.
“We’re committed to ensuring safe and effective patient care and accurate reporting of incidents helps us do that,” he said.
The incidents comprised:
- 13 falls
- 25 clinical management problems
- one ‘other’
- three hospital acquired infections
- one medication error
- one retained instrument or swab
- eight Mental Health events of which there were:
- three suicides
- one absent without leave
- four ‘others’.
The three hospital acquired infections included a Methicillin-resistant Staphylococcus aureus (MRSA) outbreak on a Waikato Hospital ward involving 16 patients and an extended norovirus infection outbreak involving six patients and 30 staff at Thames Hospital.
“We know our ongoing hand hygiene campaign is making a difference,” said Dr Watson.
The aim is to promote and encourage a culture-change and support programme for staff in knowing the ‘why, when and how’ of hand hygiene.
“The high profile we gave the campaign demonstrates the commitment to continuous quality improvement in promoting and improving safety of patients, healthcare workers and the community by reducing risk of healthcare acquired infections.
“What is pleasing about it is the way the public embrace the message. Having Sterigel at key vantage points around our hospitals helps public education.
“We’re unhappy when there are any hospital acquired infections and one of the pleasing things we’ve noted since we changed the visiting hours at Waikato Hospital recently is that there have been no incidents at all. Part of that is around the fact that our cleaners are able to get into the wards for longer periods and there is a limit on the number of visitors per patient,” said Dr Watson.
“Ironically most of the infections we find in hospitals today come from the community.”
Falls minimisation is another of Health Waikato’s six patient safety programmes. Non-slip socks, visual mapping of falls working in tandem with the productive wards programme, sensor mats, ultra low beds, Vitamin D, introduction of muscle strengthening/exercise groups, falls focus groups and falls champions are all interventions making a positive difference to patient safety.
Identification of a number of the incidents given a Severity Assessment Code (SAC) of one came about through the establishment in June of the Mortality Review Project led by Dr Watson.
“We started the project as part of the Patient Safety programme to reduce avoidable mortality and ensure shared learning across services and disciplines,” he said.
Many of them are still under review. “We’re doing those as an integrated piece of work to ensure we review them accurately and effectively and also to identify why some events only came to light as a result of the mortality review.”
Waikato DHB director of nursing and midwifery Sue Hayward said when the report of the 2009/2010 incidents went to the Health Quality and Safety Commission, 19 incidents were still under review.
“Those figures were unacceptable so while they had been investigated at a superficial level, we needed to do an in-depth evaluation and investigation into the root cause. We dedicated specific resource to this so over the last six weeks a team of four experienced and skilled members of the quality team focused primarily on investigating those serious events that were outstanding and developing the action plan,” said Mrs Hayward.
“This was agreed by a panel of representatives from nursing, medical and quality and risk. These action plans are then used by the appropriate service to implement the changes needed to prevent similar serious events from occurring again.”
Of the 19 due for completion by 30 October, only five are outstanding with two about to go to a panel review.
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Root Cause Analysis is a method used to investigate and analyse a serious or sentinel event to identify cause and contributing factors and to recommended actions to prevent a similar occurrence.
A Serious event has the potential to result in death or major loss of function, not related to the natural course of the patient’s illness or underlying condition.
A Sentinel event has resulted in an unanticipated death or major loss of function not related to the course of the patient’s illness or underlying condition.
The Severity Assessment Code (SAC) is the method used by any person who has identified an incident, to determine the appropriate action to take on that incident. The score is ascertained by rating the consequence of the incident and its likelihood of occurrence.