Nurse-related sentinel adverse events in New Zealand public hospitals

Abstract

ISQua 2012 Abstract Submission Education in Safety and Quality ISQua-2477 THE NATURE, FREQUENCY, SEVERITY AND OUTCOMES OF NURSE-RELATED SENTINEL ADVERSE EVENTS IN NEW ZEALAND PUBLIC HOSPITALS D. Rowe 1,*M. P. Finlayson 2, 1School of Nursing, The University of Auckland, Auckland, New Zealand 2Research Centre for Health and Well-being, Charles Darwin University, Darwin, Australia, Preferred Presentation Method: 15 Min Oral Presentation Will your presentation be given elsewhere, prior to the conference?: No Are you a first time presenter at an ISQua Conference?: Yes I give ISQua the permission to publish this abstract on the ISQua website: No Objectives: This research is the first national and international study to explore the nature, frequency, severity and outcomes of nurse-related sentinel adverse events (SAEs) in public hospitals. This paper will discuss the nurses’ unsafe acts that contributed to the SAEs. Methods: The study utilised document analysis to provide an in-depth exploration and interpretation of the Health and Disability Commissioner’s reports of sentinel adverse events that occurred in public hospitals across New Zealand in the years 2000 – 2010. The Health and Disability Commissioner is appointed by the government appointee to protect health consumers and to provide an independent service to patients and their families with grievances against public and private health care providers. Results: The majority of patients died, 16% required additional surgery and 13% had increased length of stay not related to additional surgery. Analysis of the nurses’ unsafe acts showed the vast majority, 92%, involved lack of or poor assessment, 80% involved lack of or poor communication, 15% involved lack of checking and back-up, and 13% involved medication administration. Conclusion: To date literature on this topic has focussed on medication errors as the primary cause of sentinel adverse events but this study contributes a deeper understanding. It demonstrates that to reduce error and improve patient safety, strategies need to be put in place to ensure nurses have the skills and knowledge to assess their patients appropriately and communicate with other health professionals as necessary. Disclosure of Interest: None Declared