The number of adverse events reported by DHBs keeps trending upwards to reach a new high of 631 but this is put down to “ever-increasing” improvement in reporting systems.

The most comment single adverse event to effect patients in our hospitals remains falls with 255 falls resulting in serious harm last year with 101 of those leading to a broken neck of femur or hip.  Followed by a range of clinical management events with the most common being delayed diagnosis or treatment (104) and pressure injuries (84).  There were 104 deaths reported to the Health Quality and Safety Commission following adverse events (compared to 79 last year but the Commission noted that not all the deaths were ‘necessarily directly related” to the reported adverse event.

The figures are contained in the Health Quality and Safety Commission’s latest 2017-18 Learning from Adverse Events report which records the health care adverse events reported to the Commission by district health boards (DHBs) and other health care providers as part of a programme to encourage an open culture of reporting and learning from events.

Commission chair Professor Alan Merry says adverse events can have a devastating effect on the person involved and their family, whānau and friends.

“Every event described here has a person at its centre. Adverse event reporting makes it possible to review each event, discover the reasons behind it and put recommendations in place with the aim of preventing anything like it from happening again.”

He said several factors were 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. The 2017/18 year also saw the introduction of the always report and review list, which has increased reporting of near misses.’

Ministry of Health Chief Medical Officer Dr Andrew Simpson said the Commission’s efforts to reduce the harm from falls shows how its applied learning makes a difference.

‘Now, with the growing maturity of this reporting, we are seeing more complex problems requiring more cross-organisational work to address them. The Ministry will be working in conjunction with the Commission, ACC and DHBs to look at how best to do this.’

A copy of the full adverse events report is available here.

2017-18 DHB Adverse Events Reports

317 clinical management events – see breakdown below* (282 previous year)

255 falls resulting in serious harm  (210 previous year)

31 healthcare associated infections (16 previous year)

20 medication/IV fluid events (19 previous year)

Other providers 2017-18 Adverse Events

91 in NZ Private Surgical Hospitals Association facilities (52 previous year)

18 in ambulance services (28 previous year)

1 in primary care (one in previous year)

9 in other providers (four in previous years

*2017-18 DHB Clinical Management Events

Delayed diagnosis or treatment 104  (70 previous year)

Pressure Injury 84 (51 previous year)

Deterioration 50 (e.g. patient deterioration not recognised or managed in expected timeframe)

Adverse outcome 33 (unexpected outcome or death)

Wrong consumer/site/side 7


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