Bay of Plenty District Health Board Medical Director Hugh Lees. Photo/file
Bay of Plenty District Health Board Medical Director Hugh Lees. Photo/file
Twelve Bay of Plenty patients were hurt in falls while at hospital, according to a report on serious adverse events this year.
A total of 13 serious adverse events were reported - up from nine reported the year prior.
Each year, health care adverse events are reported to the Health Quality & Safety Commission by district health boards (DHBs), including the Bay of Plenty District Health Board, 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 recurring.
Of the Bay patients, eight were women and five were men aged between 64 and 94 years old who were being cared for at Tauranga and Whakatane hospitals in 2014/2015 year.
The injuries listed from the serious adverse events (SAE) consisted of 13 fractures and one bleed.
Bay of Plenty District Health Board Medical Director Hugh Lees said serious adverse events were important red flags that indicate possible opportunities for improvement ''notwithstanding the distress such events cause to our patients''.
Nationally:
• 525 adverse events were reported to the Commission by DHBs (454 in 2013-14) and 67 by other providers • 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 23 cases.
''Each one of these very sad incidents has affected a patient, their family and whanau, and the health professionals who care for them,'' commission Chair Professor Alan Merry said.
''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 avoidable harm.''
Prof Merry said 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, said the involvement of patients and families/whanau when adverse events are being reviewed is integral.
''Every affected patient engaged in a review is helping us improve our work to prevent future adverse events,'' she said.
''The generosity of patients, families and whanau 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.
