![]() Half of these deaths occurred through suicide 127 people died during admission or shortly afterwards, though not necessarily as a result of the event.374 people treated in their hospitals were involved in a serious or sentinel event that was actually or potentially preventable.In the 2009/2010 fiscal year DHBs reported the following statistics: For a small minority of people, events may occur while receiving care that may cause or have the potential to cause serious harm or even death. Most people who require health care receive it safely and appropriately (Health Quality and Safety Commission, 2010). This fact sheet should be read in conjunction with the NZNO Fact Sheet: Investigations – your rights and responsibilities (NZNO, 2011) available separately. This fact sheet outlines the rights and responsibilities of members who may find themselves involved in an investigation into a serious or sentinel event. It is important that all nurses and midwives have a good understanding of the procedures and processes involved. Nurses and midwives may be involved in either a serious or sentinel event, whether they are directly or indirectly involved in the care provided. the Nursing Council of New Zealand) if this is deemed necessary. Findings from the SIRP or serious and sentinel event investigation process may also inform these investigations or an investigation by a regulatory body (e.g. ![]() they can be used in other investigations.Ĭommonly, adverse incidents that require investigation through the SIRP or serious and sentinel event investigation process may also be investigated by ACC, via a consumer or HDC complaint or by the Coroner. Therefore meeting minutes, reports and recommendations are generally discoverable i.e. In most cases, SIRP and serious and sentinel event investigation reports are not Protected Quality Assurance Activities, as the purpose is for shared learning. M&M reviews are “Protected Quality Assurance Activities”. A sentinel adverse event is life threatening or has led to major loss of function or an unanticipated death (Health Quality and Safety Commission, 2010).ĭHBS are required to provide information on Serious and Sentinel events so that this can be included in the Annual Serious and Sentinel Events report published by the Quality and Safety Commission.Ī significant incident review process (SIRP) or serious and sentinel event investigation is a different forum to a Morbidity and Mortality review (M&M). We recommend that if you are involved in a SIRP or serious and sentinel events investigation process, get advice early from NZNO.Ī serious adverse event is one that is not life threatening and has not resulted in major loss of function but requires significant additional treatment (Health Quality and Safety Commission, 2010). The significant incident review process (SIRP).The purpose of this fact sheet is to outline the rights and responsibilities of nurses and midwives who may be involved in serious and sentinel event investigations.
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