Increased reporting and learning from events focus of report

Increased reporting and learning from events focus of 2013/14 report

Increased reporting and a growing focus on learning from events are features of the release of the 2013/14 serious adverse events (SAEs) reported by district health boards (DHBs).

The annual report, released by the Health Quality & Safety Commission (the Commission) today, shows a four percent increase in events, with 454 SAEs reported, up from 437 in 2012/13.

Commission Chair Professor Alan Merry says it is encouraging to see the work and resources the health sector has put into getting better at reporting incidents of patient harm.

“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.”

He says the slight increase in SAEs is likely to reflect the health sector’s increasing commitment to improved reporting of cases.

“We expected the number of SAEs to increase as health providers improved their reporting systems, and that seems to be happening.

“It is also pleasing to see a growing range of providers reporting their serious adverse events, including private surgical hospitals, aged residential care facilities, disability services the National Screening Unit and hospices.”

In 2013/14, falls were the most frequent cause of harm reported by DHBs, making up 55 percent of all cases. Prof Merry says the high number of broken hips following falls in hospital was 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.”

Clinical management incidents were the next most frequently-reported event. The 158 reported cases included delays in treatment, assessment, diagnosis and observation. Thirty cases involved medication prescribing, dispensing or administration.

One hundred and four serious adverse events were also reported by non-DHB providers.

Over the next year the Commission will be working with the health sector to increase expertise in learning from adverse events, including providing training in the review of events. There will also be a greater emphasis on dissemination of the crucial lessons learned from reviews of serious adverse events.

Prof Merry says next week’s national Patient Safety Week is an opportunity for health sector staff to increase their event review skills.

“During the week there will be four workshops featuring international patient safety expert Dr Jim Bagian. Dr Bagian will look at the components of a safety system, how to learn from errors and how to improve systems so errors don’t recur.”

For a copy of the full report, a summary document, and questions and answers about the report, visit www.hqsc.govt.nz (note, will be live from 12 noon). DHBs will post their SAE figures on their websites.

ENDS

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