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Hospital report for
healthy outcome
WA Health has published its seventh annual report of unexpected, rare and preventable incidents in hospitals that led to patient harm or death.
The report into ‘sentinel events’ is published with the aim of ensuring similar events did not occur in future.
Director General of Health, Kim Snowball said the reports were produced in an effort to improve patient safety by sharing the lessons learned from past errors.
Mr Snowball said the WA Sentinel Event Report 2010/11 showed a total of 96 sentinel events.
| Safety improves after incidents |
“In 2010/11, sentinel events represented only 0.01 per cent of all public and private health service patient separations which is one sentinel event per 10,000 patient separations,” Mr Snowball said.
“Of the 0.01 per cent of all separations that constituted sentinel events, the number that resulted in patient deaths dropped by nearly 10 per cent from 0.0064 per cent in 2009/10 to 0.0058 per cent of total separations in 2010/11.”
He said WA Health welcomed the examination of all events and continued to be the only State where private hospitals were required to report sentinel events to their Health Department.
“All events are thoroughly investigated and lessons learned are shared across the WA Health system to further improve patient safety,” Mr Snowball said.
“Policy/procedure/guidelines, communication and ‘other’ factors were the three most commonly identified contributing factors for events in 2010/11.”
He said the majority of sentinel events continued to fall into the category of ‘other adverse event resulting in serious patient harm or death’ rather than into one of the eight nationally defined categories.
“In WA, this additional broad category allows greater learning from errors and opportunities for system improvement,” he said.
“It includes sub-categories such as complication of an inpatient fall and hospital process issue.”
The report is available online at the this PS News link.
Edition 121, 24 January 2012
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