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Serious adverse events report reflects DHBs improved reporting and commitment to learning Print E-mail
The Quarterly 2014


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The work and resources the health sector has put into getting better at reporting incidents of patient harm are reflected in the Health Quality & Safety Commission’s latest annual report into serious adverse events (SAEs), released on 30 October.
 
Commission Chair Professor Alan Merry says the improved reporting is encouraging: ‘Patients who are harmed during health care have a right to understand what happened and to expect that everything possible will be done to prevent the same thing from happening to someone else in the future.’
 
The 2013/14 report shows a four percent increase in events reported by district health boards (DHBs), with 454 SAEs, up from 437 in 2012/13.
 
The rise is a consequence of steadily improving reporting systems and DHBs’ commitment to learning from events, the Commission believes.
 
There is also a growing range of non-DHB providers reporting their SAEs, with 104 from private surgical hospitals, aged residential care facilities, disability services, the National Screening Unit and hospices.
 
Falls were the most frequent cause of harm reported by DHBs, making up 55 percent of all cases. Clinical management incidents were next, with 158 cases, including delays in treatment, assessment, diagnosis and observation. Thirty cases involved medication prescribing, dispensing or administration.
 
Prof Merry says the high number of broken hips following falls in hospital is of continuing concern.
 
“Ninety-eight people suffered a broken hip in hospital. This rate of harm is far too high, and equates to almost two patients every week suffering such an injury. This is very disappointing given the considerable effort going into reducing harm from falls, and shows this must continue to be an area of high priority for the Commission and the sector.”
 
The Commission will be working with the sector over the next year to increase expertise in learning from adverse events, including providing training in the review of events, and to strengthen the network of experienced reviewers able to offer advice when an event occurs.
 
One opportunity for health professionals to increase their review skills was the inaugural national Patient Safety Week, 3-9 November, during which there were four workshops led by world-renowned patient safety expert Dr James Bagian.
 
For the full 2013/14 SAE report, summary report and FAQs, visit http://www.hqsc.govt.nz/our-programmes/reportable-events/publications-and-resources/publication/1832/

Health Quality & Safety Commission New Zealand


The Royal Australasian College of Medical Administrators
Health Quality & Safety Commission New Zealand, , p719
www.racma.edu.au /index.php?option=com_content&view=article&id=719&Itemid=413