Source: Health Quality & Safety Commission, 7
Learning from things that go wrong in health care is a focus of
this year's adverse events report.
Each year, health care adverse events are reported to the Health
Quality & Safety Commission by district health boards (DHBs)
and other health care providers. The Commission works with these
providers to encourage an open culture of reporting, to learn from
what went wrong and put in place systems to stop incidents
- 525 adverse events were reported (454 in 2013-14)
- serious harm from falls was the most frequently reported event,
with 277 cases. Of these, 84 resulted in the patient suffering a
fractured neck of femur (broken hip)
- clinical management incidents were the next most reported
events, with 205 cases, including those relating to delays in
treatment, assessment, diagnosis, observation and monitoring
(including patient deterioration)
- incidents involving prescribing, dispensing or administration
of medication were the next most frequently reported events, with
'Each one of these very sad incidents has affected a patient,
their family and whānau, and the health professionals who care for
them,' Commission Chair Professor Alan Merry says.
'While it is too late to prevent these particular events, we owe
it to those affected to take a thorough look at what went wrong, so
we can continue to improve systems and make care safer.'
He says the rise in the number of events reported reflects the
culture change taking place in health care, with greater emphasis
on learning from systems failings.
'DHBs, other health providers and the Commission are working
together to help the sector better understand events leading to
Prof Merry says the 2014-15 report includes a special focus on
learning from cases where there has been a delay in recognition or
a lack of recognition of a patient's deteriorating condition.
'Deterioration can happen at any time in a patient's illness,
but patients are especially vulnerable after surgery and when they
are recovering from a very serious illness. Recognising and
responding to this deterioration quickly is important to avoid
cardiac arrest or admission to an intensive care unit.'
Clinical lead for the Commission's adverse events learning
programme, Dr Iwona Stolarek, says the involvement of patients and
families/whānau when adverse events are being reviewed is
'Every affected patient engaged in a review is helping us
improve our work to prevent future adverse events,' she says.
'The generosity of patients, families and whānau affected by the
incidents reported is vital. I would like to thank them for the
help they have provided.'
In 2015 the Commission has worked with DHBs and other health
service providers to increase expertise in learning from adverse
events, including providing training in the review of events.
Health professionals have also been able to share knowledge of
adverse events through Open Book learning reports.
For a copy of the full report and questions and answers visit www.hqsc.govt.nz. See individual DHB websites
for a breakdown of their figures.