Canterbury Serious Adverse Events 2018/19

Thursday 21 November 2019Media release3 minutes to read

Inpatient falls and pressure injuries continue to be the two major serious adverse events reported by Canterbury DHB for the 2018/19 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 77 adverse events identified as serious by Canterbury DHB, 47 were patients who had a fall while in hospital and 14 were hospital-acquired pressure injuries.

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

“The DHB continues to focus on identifying risk factors and tailoring falls prevention strategies to meet the needs of individual patients through the work of our Hospital Falls Prevention Steering Group. As a result of this there has been a five percent reduction in falls resulting in injury per 1000 inpatient bed days compared to the 2017/2018 year.

“Partnering with our patients and their whānau to keep them safe while in hospital is a critical part of our falls prevention strategy. By ensuring that patients, their visitors, and staff are all aware of specific fall risks and individual mobility plans for preventing a fall, we aim to minimise risk while promoting mobility and independence,” Dr Nightingale says.

Nationwide, there was a reduction in reported events for the first time since 2011/12, with the highest reported event category related to clinical management, including falls and pressure injuries.

As noted by Health Quality & Safety Commission clinical lead for adverse events Dr David Hughes, “no one should experience preventable harm when they are receiving healthcare. The sector should work together to create a safety culture where people feel able to report harm without fear of being blamed for mistakes, and we can learn from what happened.”

Dr Sue Nightingale agrees and says “at Canterbury DHB our incident reporting systems encourage 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.

“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 Dr Nightingale.

ENDS

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

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Page last updated: 21 November 2019

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