Falls major cause of hospital injuries

Hospital falls accounted for more than a quarter of 'adverse events' listed by DHBs. Photo / Sarah Ivey

Hospital falls caused more than a quarter of the major "adverse events" and several deaths listed by district health boards in their latest report on potentially preventable healthcare harm.

Eighty-five patients suffered falls and 123 clinical management problems are reported in the national tally of 308 "serious" or "sentinel" adverse events in the year to June 30.

Patient suicides accounted for 37 events - and for 40 per cent of the 92 deaths. Nearly half the deaths were associated with clinical management incidents such as delayed cancer diagnosis, delayed hospital admission of a newborn, difficulties with monitoring the fetal heartbeat during labour, and internal bleeding caused by pain relief medication.

A serious adverse healthcare event is defined in the Quality Improvement Committee's third annual report as one unrelated to the patient's condition that requires significant extra treatment, but is not life-threatening and has not caused major loss of function. A sentinel event is one that is life-threatening or causes unanticipated death or major loss of function. All the events reported are linked to 21 DHBs and were mostly in their own services.

The 308 events equate to around 0.03 per cent of the more than 950,000 public hospital admissions last year.

This was an increase on the previous year's 258 serious or sentinel events, but the rise is said to reflect better reporting, following widespread training, and greater openness at some DHBs, rather than an increase in the incidence of harm.

Waikato DHB reported the greatest number last year, 60, followed by Canterbury on 44 and Auckland on 31, but DHBs like these, with large, specialised hospitals are said to have made more progress in comprehensive reporting.

The Counties Manukau DHB's report lists seven patient falls, including one which resulted in death.

Its clinical director of quality improvement, Dr Mary Seddon, who also sits on the national quality committee, said the DHB had started a pilot project in one ward in a bid to reduce falls.

Falls were often simply accepted as "what happens" for many frail and/or sedated patients, she said. "We've decided it's not okay."

The project looked at fixing environmental hazards like slippery floors, made assessments of each patient's risk of falling, and provided for nurses to make hourly rounds of their patients.

"They meet all their needs, particularly toileting, so patients are not going to the toilet on their own if they are unstable - not ringing the call bell then trying to do it themselves."

The project had shown dramatic results: 15 falls in the four weeks before it began; one in the four weeks afterwards.

No extra staff were needed. Nurses' time had been freed up for just this sort of project by a reduction of "wasteful activities and administration work", Dr Seddon said.

"Other hospitals that have tried hourly nursing rounds have found the number of [bell] calls goes down so much they can get more done in their shift. They are not always responding to patients ringing the bell because they are anticipating what the patient needs."

* Catalogue of mistakes

Counties Manukau DHB
Patient on heart monitor was wrongly identified, which delayed medical review. Patient died. Review found incorrect and absent name labels above beds and a failure to check the patient's wrist band.

Auckland DHB
A patient with a leak from a major artery died in the emergency department after a delay in assessment due to the whole hospital being overcrowded.

Bay of Plenty DHB
Private sector lead maternity carer delayed transfer of baby to hospital after not recognising the severity of the baby's condition. The baby died. The health worker could not communicate with the mother, whose English was very limited.

Canterbury DHB
A specialist whose advice was needed by a registrar could not be contacted as the specialist's cellphone was faulty. The registrar began an emergency procedure in which he or she was inexperienced. The patient survived the procedure, but died later.

Capital & Coast DHB
Chest-pain patient developed abnormal, life-threatening heart rhythm. Cardiac monitor's audible alarms had been turned off. Delayed medical response. Resuscitation attempt failed.

Hutt Valley DHB
Delayed endoscopy (gastro-intestinal investigation) for cluster of patients. Three so far diagnosed with cancer. Two being treated. One has died.