How Do District Health Boards Respond to and Use the Serious and Sentinel Events Report?

Abstract

This thesis focuses on serious and sentinel event reporting in New Zealand. It considers how District Health Boards (DHBs) utilise the Serious and Sentinel Events (SSE) report, which is produced by the Health Quality and Safety Commission (HQSC) to improve quality and patient safety within DHBs.

Preventing adverse events is of vital importance not only to patients entering into the healthcare system but also to the healthcare industry as SSEs negatively impact on the reputation of a hospital and its clinicians. Adverse events also have economic consequences. Multiple factors influence the occurrence of adverse events and they are discussed within this thesis.

Using a qualitative research design, this study involved interviewing a range of health care professionals across 20 DHBs. The Chief Executives of the DHBs recommended the expert participants for interview. The qualitative software package QSR Nvivo10 was employed to organise and sort the transcribed data thematically.

This study suggests that DHBs have a limited response to the report. The limited response is in part a consequence of how SSEs are reported to the HQSC and issues surrounding the collation of information.

Findings suggest that quality improvement efforts across the 20 DHBs are variable. National alert systems are used internationally in relation to adverse events in healthcare. It was good to see one development in response to the SSE report, is that some DHBs have now taken to sending out alerts of serious adverse events themselves.

The SSE report has the potential to be a very useful tool in addressing SSEs. However, this qualitative study suggests that the report is underutilised and consequently some of this potential is lost. An emergent issue was a perception amongst participants that the report had limited value. Value was measured in terms of utility for internal operations, a perceived loss of value because of a lack of supporting documentation and disinterest in the occurrence of SSEs among the other DHBs.

This research has highlighted important limitations in the utility of the SSEs report and provides the opportunity to explore how future reporting and reports might be improved. It is possible that the participants have understated the value of the report. However, it remains that recording SSEs plays an important role with respect to monitoring and awareness of health care quality and safety and transparency with respect to outcomes within and across DHBs in New Zealand. Ultimately, too, this data source can allow reflection and improvements in the provision of quality and safe care for patients throughout New Zealand.