Learning from adverse events report

Thursday 21 November 2019

The annual Learning from adverse events report from the Health Quality & Safety Commission has been released.

Each year, health care adverse events are reported to the 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 happened, and put in place systems to reduce the risk of recurrence.

Between 1 July 2018 and 30 June 2019, 916 adverse events were reported to the Commission. Clinical management events continue to make up the majority of reported adverse events.

Dr David Hughes, clinical lead for the Commission’s adverse events programme, says the data in this report indicates that Māori are less likely to be reported as having had an adverse event.

‘Of those events that have been reported, Māori are affected by adverse events - such as unrecognised deterioration - where there is more scope for implicit bias to impact on their care.

‘We are currently undertaking research into whānau Māori experiences of adverse events. We plan to use this research to develop recommendations for providers on how to better meet the needs of Māori who have experienced adverse events,’ he says.

Total reported adverse events have fallen for the first time since 2011/12. Dr Hughes says in previous reports, the Commission has said that an increase in reported events does not necessarily mean an increase in harm. ‘It is more likely to be as a result of better systems to identify existing harm. Equally, it would be unwise to say that a reduction in reported events is due to a reduction in harm.’

He says no one should experience preventable harm when they are receiving health care.

‘The sector should work together to create a safety culture where people feel able to report harm without fear of being blamed for mistakes, and we can learn from what happened. We must do our best to prevent anyone else from being harmed.’

Key findings

Of the 916 reported adverse events:

- 566 were reported by DHBs

- 232 were reported from the mental health and addictions sector (DHBs only)

- 100 were reported by members of the NZ Private Surgical Hospitals Association

- 7 were reported by ambulance services - 5 were reported from the primary sector - 5 were reported by other providers - 1 was reported from a hospice.

Of the 566 events reported by DHBs:

- 278 were clinical management events

- 255 were harm because of falls

- 18 were healthcare associated infections - 11 were related to medication or IV fluid - 1 was due to documentation - 1 was related to nutrition - 2 were consumer accidents.

The embargoed report, media FAQs and DHB figures are attached. Please find the full report here at midday: https://www.hqsc.govt.nz/our-programmes/adverse-events/publications-and-resources/publication/3889

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