Health System Quality
Serious Reportable Events
As part of our efforts to improve patient safety and identify opportunities for system-wide improvements, serious patient safety incidents must be reported to the Department of Health and Wellness in accordance with the Serious Reportable Event Reporting Policy. This allows the health system to monitor, measure and evaluate serious reportable event data.
Serious reportable events (SREs) are a subset of patient safety incidents and are classified according to the following six categories. An SRE is to be part of the quarterly report for the quarter in which it is discovered. SREs newly discovered from past reporting quarters will be reported in the quarter they are discovered but will be identified or noted separately as having occurred in an earlier quarter. Note: for the purpose of these definitions, the word "patient" is used to represent a client, resident or patient.
Surgical events include incidents that occur during surgical, endoscopic or other major invasive procedures.
Product or device events include incidents that occur due to use or malfunction of equipment/devices, or contaminated medications or blood products.
Patient protection events include incidents that occur related to patient safety, security or conduct
Care management events include incidents that occur during the provision of patient care.
Environmental events include incidents that occur as a direct result of the immediate physical environment or due to patient falls.
Regulatory and Potential Criminal Events include incidents that occur that are related to health profession regulations or alleged illegal activity by another person.
EHS Prehospital Care Events include incidents that occur while receiving care from Emergency Health Services personnel prior to arrival at a hospital.
Health care professionals at the Nova Scotia Health Authority and the IWK Health Centre began providing information to the province on serious events in January 2014. Data is not available prior to this date.
Serious Reportable Event Interim Reporting 2024-2025 |
Apr - Jun |
Jul - Sep |
Oct - Dec |
Jan - Mar |
1. SURGICAL EVENTS
|
|
0
|
|
|
1a. Surgery performed on the wrong body part or the wrong patient or conducting the wrong procedure. |
|
0 |
|
|
1b. Unintended retention of a foreign object in a patient after surgery or other procedure. |
|
0 |
|
|
1c. Death during or immediately after surgery of an ASA Class I or II patient. |
|
0 |
|
|
2. PRODUCT OR DEVICE EVENTS
|
|
0
|
|
|
2a. Patient death or serious harm associated with the use of improperly sterilized instruments or equipment, or contaminated drugs, devices, or biologics provided by NSHA/IWK. |
|
0 |
|
|
2b. Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended. |
|
0 |
|
|
2c. Patient death or serious harm associated with intravascular air embolism that occurs while being cared for by NSHA/IWK. |
|
0 |
|
|
3. PATIENT PROTECTION EVENTS
|
|
1
|
|
|
3a. Discharge or release of a patient of any age, who does not have decision-making capacity in regard to decisions about the patient’s personal care, to the care of someone who does not have custody of the patient, or decision-making authority in regard to medical or personal care of the patient. |
|
0 |
|
|
3b. Patient under the highest level of observation leaves a secured facility without the knowledge of staff. |
|
0 |
|
|
3c. Patient suicide, or attempted suicide that resulted in death or serious harm, in instances where suicide-prevention protocols were to be applied to patients under the highest level of observation while being cared for by NSHA/IWK. |
|
1 |
|
|
4. CARE MANAGEMENT EVENTS
|
|
5
|
|
|
4a. Patient death or serious harm associated with a medication or fluid error including but not limited to errors involving the wrong drug, wrong dose, wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration. |
|
0 |
|
|
4b. Patient death or serious harm associated with the delay or improper administration of blood or blood products. |
|
0 |
|
|
4c. Maternal death or serious harm while being cared for by NSHA/IWK. |
|
0 |
|
|
4d. Full-term fetal or neonatal death or serious harm associated with labour or delivery while being cared for by NSHA/IWK. |
|
1 |
|
|
4e. Patient death or serious harm as a result of failure to identify and treat metabolic disturbances. |
|
0 |
|
|
4f. Stage 3 or 4 pressure ulcers or unstageable pressure injuries acquired after admission to a facility of NSHA/IWK. |
|
1 |
|
|
4g. Patient death or serious harm, related to diagnosis, as a result of the treatment provided or not provided. |
|
3* |
|
|
4h. Patient death or serious harm due to a failure to inquire whether a patient has a known allergy to medication, or due to administration of a medication where a patient’s allergy had been identified. |
|
0 |
|
|
* One of these events occurred in Q1 2024-25
5. ENVIRONMENTAL EVENTS
|
|
4
|
|
|
5a. Patient death or serious harm associated with electric shock while being cared for by NSHA/IWK. |
|
0 |
|
|
5b. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances. |
|
0 |
|
|
5c. Patient death or serious harm associated with a burn incurred from any source while being cared for by NSHA/IWK. |
|
0 |
|
|
5d. Patient death associated with a fall while being cared for by NSHA/IWK. |
|
4* |
|
|
5e. Patient death or serious harm associated with the use or lack of restraints or bedrails while being cared for in a facility. |
|
0 |
|
|
5f. Patient death or serious harm due to uncontrolled movement of a ferromagnetic object in an MRI area. |
|
0 |
|
|
*Two of these events occurred in Q1 2024-25
6. REGULATORY AND POTENTIAL CRIMINAL EVENTS
|
|
3
|
|
|
6a. Any instance of care ordered by or provided by someone impersonating a a licensed healthcare provider. |
|
3 |
|
|
6b. Abduction of a patient of any age. |
|
0 |
|
|
6c. Sexual abuse or assault of a patient that occurs on or in the property owned or controlled by the NSHA/IWK. |
|
0 |
|
|
6d. Patient death or serious harm from a physical assault that occurs on or in the property owned or controlled by the NSHA/IWK. |
|
0 |
|
|
6e. Any sexual or physical assault of a patient perpetrated by an employee, member of the medical staff,volunteer,student,or an individual under contract with a NSHA/IWK. |
|
0 |
|
|
7. EHS PRE-HOSPITAL CARE EVENTS*
|
|
|
|
|
7a. Medication administration error. |
|
|
|
|
7b. Adverse drug event during transport resulting from medication use. |
|
|
|
|
7c. Unplanned dislodgement of therapeutic device. |
|
|
|
|
7d. Hypoxia during transport. |
|
|
|
|
7e. Medical equipment failure. |
|
|
|
|
7f. Decision making and clinical judgment error. |
|
|
|
|
7g. Transport-related patient injury. |
|
|
|
|
7h. Undue delay in response or treatment for any reason, resulting in death or serious harm. |
|
|
|
|
7i. Patient death or serious harm during the offload period. |
|
|
|
|
*Reporting of EHS Pre-Hospital Care Events will begin Q4 2024-2025.
TOTAL of all Categories |
|
13
|
|
|
The Serious Reportable Events Reporting Policy has been revised starting from Q2 2024-25. Changes were made to some definitions, event categories and event types. The Q1 2024-25 data has been archived because it reflects the older version of the policy.
Why is it important to share this information?
Making this information available to the public raises the level of accountability – and demonstrates a commitment to transparency and openness. The goal is to share lessons learned and prevent the event from happening again. This new province-wide data will help us understand what's happening across the system. This information will enhance patient safety by improving and standardizing the way serious events are reported.
How is this measured?
The NSHA and the IWK must report the aggregate number of serious reportable events for each category as defined above on a quarterly basis. The Department of Health and Wellness collects and analyzes the data.
When will new information be published?
Quarterly results will be updated 35 business days following the end of each fiscal year quarter. Fiscal year quarters are:
Q1: Apr. 1 – Jun. 30
Q2: Jul. 1 – Sep. 30
Q3: Oct. 1 – Dec. 31
Q4: Jan. 1 – Mar. 31
Archived Data
Download the 2024-25 Q1 data (PDF)
Download the 2023-2024 data (PDF)
Download the 2022-2023 data (PDF)
Download the 2021-2022 data (PDF)
Download the 2020-2021 data (PDF)
Download the 2019-2020 data (PDF)
Download the 2018-2019 data (PDF)
Download the 2017-2018 data (PDF)
Download the 2016-2017 data (PDF)
Download the 2015-2016 data (PDF)
Download the 2013-2014 and 2014-2015 data (PDF)