More than 500 incidents in which hospitals failed a patient in some way – resulting in that patient’s serious injury – were reported in the last year.

A report released by the Health Quality & Service Commission this afternoon said a total of 542 adverse events had been reported by district health boards between 2016 and this year.

An adverse event is defined as an incident that results in harm to people using a health and disability service. Any event that leads to the serious harm – or death – of a person is to be reported by health and disability providers to the Commission.

The number of incidents that occurred in the last year has gone up slightly, with 520 adverse events reported in the 2015-16 period.

“The highest reported event category related to clinical management events,” the report said.

“Other highlighted reporting categories include falls, pressure injuries and healthcare-associated infections.”

Among the incidents were delays in diagnosis, treatment or follow-ups. A total of 30 of those reported events related to cancer or suspected cancer.

There were 17 reported incidents relating to retained items – eight in maternity or gynaecological theatre settings and the others to do with other surgery, wound care or interventional radiology services.

Other adverse events dealt with the wrong patient, wrong site, side, wrong treatment or procedure.

“There were eight events reported in this category, six of which occurred outside the expected operating theatre environment.”

A breakdown of the incidents were:

  • 282 clinical management events
  • 210 falls resulting in serious harm, including 77 where the patient broke their hip
  • 19 medication-related events
  • 16 healthcare-associated infections and
  • 15 other events, such as dietary management and documentation.

As well as those, there were also 86 adverse events reported by other providers:

  • 52 from the NZ Private Surgical Hospitals Association
  • 28 from ambulance services
  • one report relating to a pressure injury at an aged residential care facility
  • one relating to serious harm, as the result of a fall, from a primary health organisation
  • two incidents at a hospice relating to a pressure injury and serious harm from a fall and
  • two events at a community service facility.

Auckland District Health Board reported the most incidents in the last year with 95 adverse events logged.

Canterbury had 73 events during that time, while other district health boards in Auckland reported 48 incidents (Counties Manukau) and 45 (Waitemata).

Commission chairman Professor Alan Merry said the impact on the people involved in these incidents – and their families – was huge.

He acknowledged, therefore, that more could be done to improve safety within hospitals and health providers by looking at the learning process – and even working with those people who have been affected by an adverse event in the past.

“Partnering with consumers and whanau in the review and learning process is pivotal to improving quality and safety,” he said.

“Consumers may be able to perceive care transition and process issues including service quality that occur before, during and after adverse events that are less likely to be identified as providers.”

Source: NZ Herald


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