Toward Clinical Excellence: Learning from Experience
A Report to the Director-General of Health from the Sentinel Events Project Working Party
Date of publication: September 2001
The Sentinel Events Project Working Party members have been brought together from throughout the health sector to make recommendations to the Director-General of Health on the feasibility of implementing a mandatory event reporting system for health and disability services and related matters.
Sentinel Events - what are they?
Those events that must be reported centrally as part of the system recommended in this report. Sentinel Events result from the systems that deliver care/treatment to consumers.
Sentinel Events are not:
- events that occur as a natural consequence of the consumer’s illness, disease or condition
- events that are unavoidable, expected complications of the consumer’s illness, disease or condition.
Sentinel Events have a significant effect on the consumer, result in permanent disability or death, and result from management of the consumer’s illness, disease or condition.
The Working Party's vision is to create an environment in health and disability services that:
- supports and encourages self-learning from analysing Sentinel Events
- promotes the redesign of systems as the main method for improving safety
- supports a culture where health care workers take personal responsibility for consumer safety.
This report sets out a framework and process for reporting investigations of Sentinel Events to an independent central agency, which will evaluate them and identify strategies that enable learning at a national level, and also looks into the cost and benefits of such a system.
It addresses three key areas of activity relating to Sentinel Events:
- the local response by health and disability services when an event occurs
- the role of the central agency in reviewing actions of health and disability services and in taking immediate measures to protect the public
- the role of a central agency in ensuring lessons are learned from Sentinel Events, and implementing and monitoring actions at a national level to improve safety for consumers.
Disclaimer: This document was produced by the Sentinel Events Project Working Party and does not necessarily reflect the views and policies of the Ministry of Health.
Document availability
This publication is not available in hard copy. It is only available on this website in PDF format below.
 (PDF, 449 kB)
Note: The document that was published on 24 September 2001 contained statistical errors on pages 24 and 25. The above PDF of the document has been revised to correct these errors.
This publication has been converted to Adobe's Portable Document Format (PDF). Here is a link to information on downloading and viewing PDFs.
Related Links
Improving Quality pages
A Summary of Submissions on the Review of Processes Concerning Adverse Medical Events
Adverse Events in New Zealand Public Hospitals: Principal Findings from a National Survey
Reportable Events: Guidelines |