Harm isn't a word you associate with going to the hospital. But things do go wrong, and sometimes with tragic outcomes. But as reporter JOHN MASLIN found out, clinical leaders at Whanganui Hospital are showing the rest of the country how to bring about positive change.
Whanganui Hospital had 17 adverse events last year.
And they make sobering reading.
In one case a surgical drain was left in a patient; a biopsy that should have been seen by an urologist wasn't; a surgical clip used during in a previous operation was left in a patient obstructing her ureter; one patient was given an injection into the wrong side of their spine.
And during surgery on a patient's left big toe joint the drill bit fractured, the tip remaining in the bone was unable to be removed.
The information is in the Health Quality and Safety Commission (HQSC) 2015-2016 report. But as with every adverse event at the hospital, there were in-depth reviews and changes in procedure put in place to prevent the same thing happening to another patient.
Sandy Blake says even seemingly minor reductions in harm events with save the health budget thousands of dollars. PHOTO/STUART MUNRO
Six years ago Sandy Blake arrived at the Whanganui District Health Board to head a team charged with investigating any and every incident occurring within our hospital. Her role was to co-ordinate all the patient-safety and quality work.
It was work that went beyond the hospital campus, with the team working with aged-care residences and primary health organisations across the Whanganui region.
Mrs Blake, the DHB's director of nursing, has had that work recognised at a national level and she's now national clinical lead for the HQSC's falls programme.
They've had marked success with the falls prevention programme at Whanganui Hospital.
In the last year the commission said only three DHBs around the country had no falls that resulted in fractured hips. One of these is Whanganui's hospital.
In fact in the last two years there hasn't been one patient fall and suffer a fractured hip in our hospital. Four or five years ago there was five or six a year.
"Doesn't sound like much but it costs thousands of dollars to fix those breaks, and thousands more in rehab and usually in aged care. So it costs money when this harm happens. But above all it creates immense suffering for the person involved and their family and you can't put a dollar value on that," she said.
Mrs Blake's approach is simple - this is about people not money.
"The people suffering falls are usually our most vulnerable people, suffering cognitive recognition issues and have probably had a handful of major diseases. They've had enough suffering but then they fall and break their hip."
The "light bulb moment" for her staff came when they realised 60 per cent of patients involved in falls had cognitive impairment. And it wasn't just about fractures. It highlighted issues around older people's bone health.
Whanganui's elderly demographic is rising and many have osteoporosis. Without good bone density breaks are more likely.
"We've now got GPs in our region working with those people with osteoporosis to tackle the problem much earlier."
Mike Sandlant and Ruth Beadle are regulars at one of the Steady As She Goes programmes run by Age Concern around the region. PHOTO/STUART MUNRO241116WCSM
She said about 70 people outside the hospital will have a fall and break a hip every year in our community and that's why improving bone health was a target.
Mrs Blake said cognitive impairment also showed some in the community needed special care. If they're in hospital it often meant they became more confused and the more confused the more likely they are to get out of bed, lose their balance and fall.
"We've put these patients under close care with someone caring for them all the day. It's about keeping them safe, calm and less impulsive. And we can say that since focusing on cognitive impairment, our harm rates have decreased."
She said the work happening in the hospital was extending into the community and Whanganui Hospital staff are among the very few in the country who do go into
