DHB reports adverse event increase

22:18, Nov 20 2012

Capital and Coast District Health Board has reported 19 serious and sentinel events at its hospitals in the past year - a slight increase on the previous year.

Hutt Valley reported 10 events, Wairarapa reported four and Hawke's Bay had 11 events.

The country's 20 district health boards reported 360 events for the year ending June 30, 2012. The Health Quality and Safety Commission's serious and sentinel report shows 91 patients died, but not all deaths were necessarily a result of the adverse event.

Each DHB will release details of events today.

A serious adverse event is one that leads to significant additional treatment but is not life-threatening, and has not resulted in a major loss of function.

A sentinel adverse event is life-threatening or has led to an unexpected death or major loss of function.


Nationally, the number of falls in hospitals had dropped, but clinical management events, delayed treatment and suspected in-patient suicides had increased.

Not all events were preventable, but "many involved errors that should not have happened," commission chairman Professor Alan Merry said.

"In some tragic cases errors resulted in serious injury or death. Each event has a name, a face and a family, and we should view these incidents through their eyes."

The increase in delayed treatment events highlighted an increasing trend.

''In a modern health care system these events quite should not happen, yet DHB reporting suggests they are becoming more frequent,'' Mr Merry said.

Suspected in-patient suicides had leapt from three in the previous year to 17, but did not appear to be an increasing trend.

Most cases involved mental health patients, however two patients were in general wards.

The number of falls, which account for nearly half of all events, had declined for the first time since reporting began six years ago.

While this was a positive step, Mr Merry said too many people were still being harmed while receiving health care.

"This is not about apportioning blame. This is about learning from our mistakes and making our health and disability services safer so patients receive the care they need, without needless harm.''

The aim of the report is to stimulate discussion about adverse events and identify areas for improvement.
It highlighted Capital and Coast's new system that enables GPs and health care providers in the community to report incidents involving patients receiving hospital care.

Instead of an elaborate and expensive online tool, they created a simple form that can be emailed to the DHB, which had seen several processes improved.

Wairarapa was also praised for a simple solution resulting in a reduction in medication errors.

A red square was created with duct tape on the floor by the controlled drugs cabinet in the medical and surgical ward at Wairarapa Hospital.

When nurses are standing in the square other staff know they are concentrating on medication and do not disturb them.

District health board serious and sentinel events 2011/12:

Adverse events reported by DHBs for 2011-12 include:

170 falls, a 13 per cent decrease from the 195 falls reported the previous year. Falls represent 47 per cent of all events.

111 clinical management events, up from 105 in the previous year These represent 31 per cent of all events reported and include 17 cases of delayed treatment due to failures in hospital systems.

18 medication errors, down from 25 the previous year.  These represent 5 per cent of all events.

17 suspected in-patient suicides, up from three the previous year.  These represent 5 per cent of all events.

Related story: Ten die in Capital and Coast care

Contact Bronwyn Torrie
Health reporter
Email: bronwyn.torrie@dompost.co.nz
Twitter: @brontorrie

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