By: Samantha Olley

Eleven people died in the Lakes District Health Board area in 2017/2018 as a result of shortfalls and system errors, prompting the DHB to make a range of improvements.

The 11 deaths were among 21 serious adverse events in the Rotorua-Taupō area during the 2017/18 period.

Of the 21 serious adverse events, the Lakes DHB reported 12 general events, two near misses and seven mental health events, all of which resulted in death.

Thirteen of the 14 general events and near misses occurred in Rotorua, and the other was in Taupō.

The DHB said 10 related to clinical processes such as assessment, diagnosis, treatment, and general care, three were hospital-acquired infections and one was a fall.

Quality risk and clinical governance director Dr Sharon Kletchko said the DHB regretted harm to patients and whānau as the result of its services.

Reporting serious adverse events means we not only open up to our community about these events but the process enables us to go the next step, which is making sure it does not happen again.”

The Lakes DHB has made a range of improvements after shortfalls and system errors involved in the 21 adverse events were identified.

Some of the changes include implementation of a new falls assessment and care plan document and the establishment of a network of falls nurses with extra training and regular study days.

An information pack has also been developed for the families of patients who die suddenly in hospital and reviews of mental health triage and multidisciplinary team processes are under way.

Lakes District Health Board map. Image / File

A crisis assessment and treatment team will now be based in Taupō.

There have also been changes to radiology protocol and information systems, and guidelines and education packages have been developed related to paediatrics.

The 12 general events reported were down from 13 in 2016/17 and included four deaths, down from five reported last year.

The DHB’s serious adverse events reporting also included those in Mental Health and Addictions Services, from January 2017 to June 2018.

All of the seven mental health events resulted in a patient death in the 18-month period in the Lakes DHB.

Adverse events reported for the 2017/2018 year in New Zealand health and disability services. Image / Supplied

Four were patients in Rotorua, two in Taupō, and one was across both sites.

Nationally, the Health Quality and Safety Commission said DHBs were steadily improving reporting systems and more incidents were being reported and reviewed each year.

Commission chairman Professor Alan Merry said adverse events could be “devastating” for those affected.

“Every event described here has a person at its centre.”

In total, 982 adverse events were reported in the last year by private and public health services in New Zealand.

That includes at least 208 suspected suicides reported by DHBs in the last year, while or soon after the person was in public health care.

Lakes DHB changes resulting from 2017/2018 adverse events

  • New falls assessment and care plan document implemented. Network of falls nurses set up, with extra training and regular study days.
  • Radiology protocol changed to detect a particular diagnosis.
  • New paediatric analgesia guideline developed and included in medication safety training for new house officers.
  • Paediatric Early Warning Score education package developed and placed on orientation programme for new house officers.
  • Radiology information system changed. Order of old and current films is now always consistent.
  • A print-out of most recent smear report logged with National Cervical Screening Programme is now routinely available for all women at gynaecology clinic.
  • Information pack developed for family/whānau of patients who die suddenly in hospital.
  • Reviews of mental health triage and multidisciplinary team processes under way.
  • Crisis assessment and treatment team now based in Taupō.

Reported adverse events over the 2017/18 period
12 general events and 2 ARR events over 12 months

  • 10 related to clinical process (assessment, diagnosis, treatment and general care), included the two ARR events. Four of these events resulted in death.
  • Three Hospital Acquired Infections
  • One Fall
  • 13 events occurred in Rotorua, 1 in Taupo

Seven Mental Health events all resulting in death (over a period of 18 months)

  • Four in Rotorua
  • Two Taupō
  • One across both sites

A further two events were withdrawn since the HQSC cut-off date – one general, one MH&AS. Another event was downgraded from a serious adverse event but remains in the ARR category.

Source: NZ Herald


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