How public hospitals respond to and use a national serious and sentinel events report: A qualitative study in New Zealand

How and if public hospital leaders in a national health system use an annual Serious and Sentinel Events (SSE) report, an aim of which is to stimulate improvements in health care quality and patient safety, is an important question that is under-researched. This exploratory qualitative study in New Zealand using semi-structured interviews was undertaken in response. Interviewees included 29 representatives in patient safety leadership roles from 20 hospital districts, each of whom were recommended by their Chief Executives. Four themes describing factors contributing to the use of the SSE report were identified: response to the report itself; perceived use of and value of the report as a quality improvement tool; collaboration amongst hospitals around the findings; and, the priority given to improving quality within respondents' healthcare organisations. This article provides examples of these themes and how they relate to the use of the SSE report as a quality improvement tool. The article concludes that an annual SSE report has the potential to be a very useful tool for health care leaders in addressing SSEs. However, it also suggests that the report is underutilised and consequently some of this potential is lost. This may be explained by hospital capacity to absorb information from, and respond to, the SSE report.