KEY POINTS:
Some health boards are good at drawing up policies on safety, but not so good at doing anything about it, the Health and Disability Commissioner said today.
Ron Paterson ordered a review of services nationwide after the death of a 50-year-old man from pneumonia at Wellington Hospital three years ago.
The country's 21 District health Boards (DHBs) were asked what safeguards they had in place to prevent a similar case happening in their hospitals.
All but one acknowledged a similar tragedy could occur in their hospitals, but most were working to improve their systems, the report said.
The review, by Counties-Manukau physician and quality improvement expert Mary Seddon, found DHBs that were policy-heavy but in some cases light on actual safety systems.
Dr Seddon said some DHBs were mired in an "individual blaming culture" - believing if doctors just concentrated harder, errors would not happen.
In an extreme example of the policy-heavy culture, one DHB had eight policies relating to smoking, the review found.
Dr Seddon said a collective approach to some of the safety issues would be beneficial and called on government leadership to address the problem.
The nationwide review followed a damning report released in April on the case of the Wellington patient, known only as "Mr A", from Mr Paterson.
In the report Mr Paterson said he found "serious failings" in the care provided.
He said simple procedures could have saved the life of the patient, who died 40 hours after admission to the hospital with classic signs of a chest infection.
Dr Seddon said the DHBs had identified many areas for improvement, with 10 key areas including handover of patient care between shifts; provision of High Dependency Care units; timely reviewing of X-rays; and early assessment and planning in the Emergency Department.
She said the DHBs seemed to fall into three categories. The West Coast DHB and Canterbury DHB both stood out in the first category as boards that "really understood what a safety culture was and demonstrated systems thinking," she said.
However, there were also those that "superficially used the language of safe and quality care but their action plans did not give confidence," she said.
Lastly, there were DHBs that had not moved on from the individual blaming culture. "They continue to believe that if doctors just concentrated harder, worked harder and were more careful, then medical errors would not occur," she said.
Dr Seddon said this contradicted medical findings over the last 10 years which recognised humans made errors, even when they were experts, and that a safe system predicted errors and set up defence systems to prevent them affecting the patient.
The last category was summed up by the response of one DHB which said: "We don't believe that we could put in place any system to prevent poor outcome due to negligence by staff".
Dr Seddon said despite this lack of understanding by some DHBs of the importance of systems in creating a safe hospital culture, there was still a "plethora" of policies produced by almost all DHBs.
However, there was a lack of auditing to see how well policies were followed, with some DHBs "apparently thinking that having a written policy was an end in itself".
She said national collaboration could speed up improvements.
- NZPA
