Serious Adverse Events 2016/17

Friday November 24, 2017

Inpatient falls continue to be the single major serious adverse events (SAE) reported by the Canterbury DHB for the 2016/17 financial year.

The release of a Serious Adverse Events report by each DHB is a Health Quality & Safety Commission (HQSC) initiative. The reports highlight events which have resulted in significant additional treatment, major loss of function, are life threatening or have led to an unexpected death.

Of the 73 adverse events identified as serious by the Canterbury DHB, 29 were patients who had a fall while in hospital – the same number as reported the previous year and 25% less than 2014/15 figures.

Chief Medical Officer Dr Sue Nightingale says "there continues to be a focus on identifying risk factors and tailoring falls prevention strategies to meet the needs of individual patients while they are in hospital and when they return home."

A further 20 patients sustained hospital-acquired pressure injuries. These have been included in Canterbury DHB SAE reporting for the first time, with each case leading to an independent review and recommendations.

Canterbury District Health Board is currently working with ACC to design and implement a district wide three year pressure injury prevention improvement programme. "The Canterbury Health Pressure Injury Advisory Group has been proactive in developing and implementing pressure injury prevention strategies and the broadening of the programme will result in a data driven improvement approach to prevention across the district," says Sue Nightingale

Some adverse events marked as serious in the July report have since been downgraded following further investigation, though each event is still followed up with a review process.

Nationwide, and in Canterbury, the highest reported event category related to clinical management, including pressure injuries and delayed or missed diagnosis or treatment. 

Sue Nightingale adds that "serious adverse events are reviewed through a formal process with the aim of providing feedback to patients and families so they are aware of contributing factors and causes and how we intend to make our systems safer."

As noted by HQSC Chair Professor Alan Merry, "an increase (in reported events) probably reflects a change in culture towards increased transparency and learning from system failings, rather than an increase in adverse events themselves."

Sue Nightingale agrees, "at Canterbury DHB the implementation of an electronic incident reporting system means that staff feel comfortable reporting events and 'near misses'.  By looking into the factors that contributed to these events and reviewing what happened we can learn and improve our systems and processes to make them safer."

"The emphasis is on improving systems to reduce the chance of something similar happening in the future. While we aim for zero harm, having a culture where staff are encouraged and supported to report near-misses and adverse events is vital to ensure the quality and safety of our treatment and care is constantly improving," says Sue Nightingale. 

ENDS

Page last reviewed: 24 November 2017
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