Health System Quality

Serious Reportable Events

Every year in Nova Scotia, there are about 100,000 inpatient and day visit surgeries and procedures, 665,000 emergency room visits, 100,000 ground and air ambulance transports, and more than a million diagnostic imaging tests. The health care professionals who deliver these services strive to provide safe, quality health care to Nova Scotians. Unfortunately, even with the best systems in place, things sometimes go wrong. 

These are called patient safety incidents. As part of our efforts to improve patient safety and identify opportunities for system-wide improvements, serious incidents must be reported to the Department of Health and Wellness in accordance with the  Serious Reportable Event Interim Reporting Policy. This allows the health system to monitor, measure and evaluate serious reportable event data.

While not all patient safety incidents are preventable, we can reduce the chances of something occurring by continually learning and improving our systems. Through serious event reporting and reviews, the health sector gains valuable information which can help it to better understand and identify how the safety of patients can be enhanced and improved. Identifying common issues and trends will help inform strategies to further improve patient safety programs and reduce the occurrence of patient safety incidents.

Serious reportable events (SREs) are a subset of patient safety incidents and are classified according to the following six categories. Events are reported in the quarter that it is reasonably clear an SRE occurred. Reporting is done with the best available evidence at quarter’s end. 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.

Criminal events include incidents that occur related to alleged illegal activity by another person.

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 Policy
Quarter 1 Results
Q1 - April to June - 2016-2017

NSHA TOTAL IWK Subtotal

1. SURGICAL EVENTS 3 1 4

a. Surgery performed on a wrong body part

1 0 1
b. Surgery performed on the wrong patient 0 0 0
c. The wrong surgical procedure performed on a patient 0 0 0
d. A foreign object left in a patient after surgery or other procedure 1 1 2
e. Death during or immediately after surgery of an ASA classification I-II patient 0 0 0
f. An adverse health event leading to death or serious disability associated with any other surgical event while a patient is receiving a health care service provided by a NSHA or the IWK Health Centre 1 0 1

2. PRODUCT OR DEVICE EVENTS 0 0 0

a. Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by a NSHA or the IWK Health Centre

0 0 0
b. 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 0 0
c. Patient death or serious disability associated with intravascular air embolism that occurs while being cared for by a NSHA or IWK Health Centre 0 0 0
d. An adverse health event leading to death or serious disability associated with any other product or device while a patient is receiving a health care service provided by a NSHA or IWK Health Centre 0 0 0

3. PATIENT PROTECTION EVENTS 10 0 10

a. An infant discharged to the wrong person

0 0 0
b. Patient death or serious disability associated with a missing patient 0 0 0
c. Patient suicide, or attempted suicide resulting in serious disability while being cared for by a NSHA or the IWK Health Centre (includes both inpatients and outpatients) 10 0 10
d. An adverse health event leading to death or serious disability associated with any other patient protection event while a patient is receiving a health care service provided by a NSHA or the IWK Health Centre 0 0 0

4. CARE MANAGEMENT EVENTS 8 0 8

a. Patient death or serious disability associated with a medication or fluid error including, but not limited to, errors involving the wrong drug, the wrong dose, the wrong patient, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration

0 0 0
b. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products 0 0 0
c. Maternal death or serious disability while being cared for by a NSHA or the IWK Health Centre 0 0 0
d. Full-term fetal or neo-natal death or serious disability associated with labour or delivery while being cared for by a NSHA or the IWK Health Centre 1 0 1
e. Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for by a NSHA or the IWK Health Centre 0 0 0
f. Neonatal death or serious disability, including kernicterus, associated with failure to identify and treat hyperbilirubinemia 0 0 0
g. Stage 3 or 4 pressure ulcers acquired after admission to a facility of a NSHA or the IWK Health Centre 6 0 6
h. Patient safety incident, related to diagnosis, where the treatment provided or not provided leads to patient death or serious disability 1 0 1
i. An adverse health event leading to death or serious disability associated with any other care management event while a patient is receiving a health care service provided by a NSHA or the IWK Health Centre 0 0 0

5. ENVIRONMENTAL EVENTS 6 0 6

a. Patient death or serious disability associated with electric shock while being cared for by a NSHA or the IWK Health Centre

0 0 0
b. 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 0 0
c. Patient death or serious disability associated with a burn incurred from any source while being cared for by a NSHA or the IWK Health Centre 0 0 0
d. Patient death associated with a fall while being cared for by a NSHA or the IWK 2 0 2
e. Patient death or serious disability associated with the use or lack of restraints or bedrails while being cared for in a facility 0 0 0
f. An adverse health event leading to death or serious disability associated with any other environmental event while a patient is receiving a health care service provided by a NSHA or the IWK Health Centre 4 0 4

6. CRIMINAL EVENTS 0 0 0

a. Any instance of care ordered by or provided by someone impersonating a doctor, nurse, pharmacist, or other health care provider

0 0 0
b. Abduction of a patient of any age 0 0 0
c. Sexual assault of a patient that occurs in facilities or on grounds owned or controlled by a NSHA or the IWK Health Centre 0 0 0
d. Patient death or serious disability from a physical assault that occurs in facilities or on grounds owned or controlled by a NSHA or the IWK Health Centre 0 0 0
e. Any sexual or physical assault of a patient perpetrated by an employee, doctor, volunteer, student or an individual under contract with a NSHA or the IWK Health Centre 0 0 0
f. An adverse health event leading to death or serious disability associated with any other criminal event while a patient is receiving a health care service provided by a NSHA or the IWK Health Centre 0 0 0

TOTAL of all Categories 27 1 28

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 2015-2016 data

Download the 2013-2014 and 2014-2015 data