Efforts to reduce 'adverse events'

18:34, Nov 21 2013

There have been 17 "serious adverse events", including one death, recorded by South Canterbury health providers in the past year.

That figure makes up 3 per cent of the 489 nationwide incidents reported to the Health Quality & Safety Commission. Of those incidents, 82 patients died, but not necessarily as a result of the adverse event.

The South Canterbury District Health Board has confirmed it had one death, which could be "directly attributable" to the event.

Of the 17 incidents in South Canterbury, 13 resulted in fractures, one meant the patient's stayed longer in hospital and two patients suffered head injuries.

Board chief executive Nigel Trainor said a "culture" of open disclosure was encouraged so lessons could be learnt from the events and improvements made to services.

"All adverse events are extremely regrettable and SCDHB investigate each SAE (serious adverse event) extensively to enable us to learn from the incident in order to make improvements and prevent a recurrence, where possible."


Nationally there were 253 cases of serious harm from falls. Of those, 106 patients suffered a broken hip, 24 sustained serious head injuries, 21 broke an arm, 21 broke their pelvis, 14 broke femurs and the remaining 67 were classified as having an "other" injury.

There were 24 cases related to medication, including 11 relating to an incorrectly prescribed drug or drug dose. Four incidents related to infections, five related to transport and a five involved equipment.

The board has confirmed falls risk assessments and falls prevention action plans were conducted when the patients were admitted, but were not always updated when the patient's health status changed.

The board also noted vitamin D was not routinely considered for patients over 65, who were in aged residential care at the time of the incident. Vitamin D is believed to help reduce falls, as well as the severity of fall-related injuries, by strengthening muscle and bones and improving posture and balance.

South Canterbury reported another 17 serious adverse events in the 2011/2012 year and 10 in 2010/2011. In 2009/2010 there were nine and in 2008/2009 there were seven.

The board is working to improve those statistics using a range of initiatives. A range of products are being trialled, which aim to alert staff before a patient attempts to get out of bed. The board is also looking at ways to improve its risk assessment tools and is trialing warning devices, including chair pressure devices, which sound an alarm as the patient moves to stand up.

Mr Trainor said there had been some encouraging developments from initiatives already in place.

"We cannot definitively say we have stopped 'X' number of falls, however through the work in AT&R currently we have had .... 129 days since we have had a fall with serious harm."

The Timaru Herald