Fewer falls at Tauranga Hospital - SAE 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.

In Tauranga, the Bay of Plenty District Health Board experienced fewer events than last year with the fewest, per 100,000 bed days, of any DHB in the country.

The DHB stated it had established a falls prevention programme which was continually monitored and reviewed.

The programme involves two falls working groups - One reviews the organisational Reportable Event Forms (REFs) related to a fall and the second monitors what is happening nationally, regionally and locally.

The DHB stated the falls prevention programme had an emphasis on documented falls risk assessment and care plan.

Commission Chair Professor Alan Merry said it was 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."

Prof Mery said the slight increase in SAEs was 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 said 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.