Canterbury Serious Adverse Events 2017/18

Friday 7 December 2018Media release3 minutes to read

Inpatient falls and pressure injuries continue to be the two major serious adverse events reported by Canterbury DHB for the 2017/18 financial year.

The release of a Serious Adverse Events Report by each DHB is an initiative led by the Health Quality and Safety Commission. 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 82 adverse events identified as serious by Canterbury DHB, 50 were patients who had a fall while in hospital and 14 were hospital-acquired pressure injuries.

Canterbury DHB Chief Medical Officer Dr Sue Nightingale says the Canterbury Health System has made great progress in reducing the harm caused by falls but it's still a major cause of harm, both in hospitals and in the community. 

“We recognise the impact falls continue to have on the community and continue to implement a number of initiatives in our hospitals that have come from the work our Hospital Falls Prevention Steering Group have undertaken.

“The initiatives that we have up and running in our hospitals focus on the patient recovery model, including thorough assessments of a patient’s mobility needs to get them up and moving, with the required support identified to prevent falls,” Sue says.

Nationwide, there was an increase in reported events, with the highest reported event category related to clinical management, including falls and pressure injuries.

As noted by Health Quality and Safety Commission Chair Professor Alan Merry, “several factors are likely to have influenced this increase, including changes in reporting requirements and the Commission’s quality improvement programmes placing a spotlight on specific areas. In addition, staff have reported more events because DHBs have worked diligently to increase their ability to recognise and report adverse events.”

Sue Nightingale agrees and says “at Canterbury DHB the implementation of an electronic incident reporting system enables staff to report adverse events. 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 adverse events is vital to ensure the quality and safety of our treatment and care is constantly improving,” says Sue.

ENDS

More information: Canterbury DHB Serious Adverse Events Reports are available in our online Document Library.

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Page last updated: 7 December 2018

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