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Canterbury Serious Adverse Events 2019/20

Thursday 10 December 2020Media release3 minutes to read

Inpatient falls and pressure injuries continue to be the two major serious adverse events reported by Canterbury DHB for the 2019/20 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, 31 were health care associated pressure injuries.

Canterbury DHB’s Chief Medical Officer Dr Sue Nightingale says the Canterbury Health System is continuously implementing improvements to reduce the harm caused by healthcare associated pressure injuries.

“The DHB continues to focus on identifying risk factors and tailoring pressure injury prevention strategies to ensure the safety of patients within our hospital and in the community.

In the past year, we have established a Transalpine Pressure Injury Prevention Community of Practice to strengthen best practice across the Canterbury and West Coast health systems, upskilled nurses as Pressure Injury Prevention Link Nurses to better equip them to prevent, assess and manage pressure injuries and, in partnership with ACC, produced an education video on preventing pressure injuries in a community and hospital setting.

“We have also upgraded our mattresses to dual purpose ones specifically designed to reduce and relieve pressure, implemented a high protein diet and teaching tools for patients who have pressure injuries to aid their recovery, developed online training for nurses and upgraded our policies,” Dr Nightingale says.

Nationwide, there was a total of 975 reported events, with the highest reported event category related to clinical management.

As noted by Health Quality & Safety Commission clinical lead for adverse events Dr David Hughes, “event numbers are closely linked to reporting rates, and an increase doesn't necessarily mean more adverse events have occurred. What it may in fact demonstrate is organisations continuing to develop an open culture where events are reported and learnt from, rather than an increase in preventable harm.”

Dr Sue Nightingale agrees and says “Canterbury DHB has robust incident reporting systems that 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 strong incident reporting 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.


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


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Page last updated: 10 December 2020

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