Toward Clinical Excellence: Learning from Experience

Published online: 
02 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.

Publishing information

  • Date of publication:
    02 September 2001
  • Ordering information:
    Only soft copy available to download
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