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.

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 2021-2022

Apr - Jun

1. SURGICAL EVENTS 2

a. Surgery performed on a wrong body part

1      
b. Surgery performed on the wrong patient 0      
c. The wrong surgical procedure performed on a patient 0      
d. Retention of a foreign object in a patient after surgery or other procedure 1      
e. Death during or immediately after surgery of an ASA classification I-II patient 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 0      
 

2. PRODUCT OR DEVICE EVENTS 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      
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      
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      
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      
 

3. PATIENT PROTECTION EVENTS 2

a. An infant discharged to the wrong person

0      
b. Patient death or serious disability associated with a missing patient 0      
c. Patient suicide, or attempted suicide resulting in serious disability while being cared for by a NSHA or the IWK Health Centre 2      
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      
 

4. CARE MANAGEMENT EVENTS 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

1      
b. Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products 0      
c. Maternal death or serious disability while being cared for by a NSHA or the IWK Health Centre 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 0      
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      
f. Neonatal death or serious disability, including kernicterus, associated with failure to identify and treat hyperbilirubinemia 0      
g. Stage 3 or 4 pressure ulcers acquired after admission to a facility of a NSHA or the IWK Health Centre 6(*)      
h. Patient safety incident, related to diagnosis, where the treatment provided or not provided leads to patient death or serious disability 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      

* One of these 6 events occurred in Q4 2020-21 (Jan-Mar 2021)
** This event occurred in Q2 2020-21 (Jul-Sep 2020)

 

 

5. ENVIRONMENTAL EVENTS 1

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

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      
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      
d. Patient death associated with a fall while being cared for by a NSHA or the IWK 1      
e. Patient death or serious disability associated with the use or lack of restraints or bedrails while being cared for in a facility 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 0      
 

6. CRIMINAL EVENTS 0

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

0      
b. Abduction of a patient of any age 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      
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      
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      
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      
 

TOTAL of all Categories 13

 
 

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 2020-2021 data

Download the 2019-2020 data

Download the 2018-2019 data

Download the 2017-2018 data

Download the 2016-2017 data

Download the 2015-2016 data

Download the 2013-2014 and 2014-2015 data