Making health and disability services safer

Serious adverse events 201213 November 2013

Foreword
This is a summary of the full report of the serious adverse events reported to the Health Quality & Safety Commission between 1 July 2012 and 30 June 2013. Everyone involved in caring for consumers of health and disability services is strongly encouraged to read the full report, which is on the Commissions website: www.hqsc.govt.nz For the rst time this report includes incidents that took place outside district health board (DHB) hospitals. This is an important step towards integrating the wider health and disability sector into the Commissions national programme to prevent harm from serious adverse events. More serious adverse events were reported in 201213 than in previous years. Much of this increase is likely to be due to improved reporting. As was the case last year, harm from falls accounted for over half of all events reported. In a parallel process, the Commission is introducing quality and safety markers and indicators to monitor progress in reducing harm in key areas.

All serious adverse events 201213 by event type

Falls 253 Clinical management events 179 (including 4 near misses) Medication events 24 Other patient accidents (not falls) 9 Healthcare associated infections 4 Equipment-related events 5 Transport-related events 5 Other events 10

Total events: 489

All serious adverse events 201213 by reporting provider

DHBs 437 Private surgical hospitals 3 Age-related residential care facilities 7 Hospices 1 Total events: 489 Disability services 7 Ambulance services 29 Primary health organisations 1 National Screening Unit 2 Primary care 2

Improved reporting
Changes made by DHBs are likely to have resulted in the increase in the number of serious adverse events reported. These changes include DHBs checking other information systems (ie, ACC claims) to ensure all serious adverse events are captured, and reporting as serious adverse events those cases with a serious 1outcome for the patient, but where the review showed there had been no reasonably preventable cause. Serious adverse event reporting 200607 to 201213
437 372 308 258 182 DHBs Other providers 370 360

52

200607 200708 200809 200910 201011 201112 201213

11

Serious adverse events 201213

Serious adverse event reporting 201213
23

67
13

17

47
9 7 8

45 36 21 20 36

50

29 12 1 2 1 3 Private surgical hospitals Primary health organisation National Screening Unit Hospice
200809 200910

17 11 11

17 9 9 201213 11 4 5 Tairawhiti DHB Waikato DHB Taranaki DHB 4 Waitemata DHB West Coast DHB Wairarapa DHB 5 Whanganui DHB

7 7 200708

201011

201112

Nelson Marlborough DHB

Capital & Coast DHB

Bay of Plenty DHB

Hawke's Bay DHB

Lakes DHB

Counties Manukau DHB

Disability services

Mid Central DHB

Northland DHB

Auckland DHB

Ambulance services

Canterbury DHB

Hutt Valley DHB

South Canterbury DHB

Aged residential care

Southern DHB

Falls
Incidents resulting in serious harm from falls are the most frequently reported serious adverse events. The number of falls reported has increased from previous years to 253 (244 DHB, 9 other providers) but this is probably due to factors affecting reporting, rather than an increase in events. Falls serious adverse events 200708 to 201213

244 195 170 128 85 56 9 200708 200809 200910 201011 201112 201213 DHBs Other providers

DHB clinical management events

Clinical management incidents are the second most frequently reported events, with 179. The increased reporting of pressure injuries is captured within this category, and the cross-checking of internal information systems with ACC claims is also likely to have increased reporting. Clinical management serious adverse events 201213

7% 8%

2%

29%

Diagnosis Adverse outcome Treatment Monitoring Retained item Wrong procedure/patient General care Equipment fail

7%

11%

20% 16%

Commission programmes to reduce harm

The Commission runs a number of harm-prevention programmes, which are part of its Open for better care national patient safety campaign.

Reducing harm from falls

Falls prevention is everyones business and reducing harm from falls was the rst topic of the Commissions Open for better care campaign. Falls prevention is challenging for all health care professionals and providers, especially as our population ages. The Commission is focused on supporting health professionals to put in place the best evidence-based strategies to help keep patients safe while receiving health care. Our rst priority has been the hospital environment, and the focus is extending to the age-related residential care sector and community settings.

Sandy Blake
Clinical Lead, Falls

Reducing harm from medication errors

We all have a responsibility to learn from reported events and work to identify how we can reduce patient harm. A key driver for the Commissions Medication Safety Programme is to continually identify quality improvement initiatives to ensure the safe and quality use of medicines. The programme has multiple workstreams with the following core objectives: reducing harm from high-risk medicines improving prescribing and administration of medicines improving the transfer of medicine information at transition points of care providing expert advice and strategic thinking on medication safety.

Dr Mary Seddon
Clinical Lead, Medication Safety

Reducing perioperative harm

The Commission has a work programme to reduce unintended harm to patients during the perioperative stages of their care. This covers the planning of a procedure, the procedure itself and the time immediately afterwards. The Commission has been encouraging hospitals to use a key process the World Health Organizations Surgical Safety Checklist. It covers a set of crucial safety checks and helps improve teamwork and communication between members of the operating team, who may not have worked together before.

Ian Civil

Miranda Pope

Clinical Lead, Nursing Clinical Lead, Reducing Perioperative Reducing Perioperative Harm Harm

Infection prevention and control (Reducing surgical site infections)

Reducing surgical site infections (SSIs) is one component of the Commissions Infection Prevention and Control Programme. The Surgical Site Infection Improvement Programme was established to standardise the collection and reporting of SSIs and to encourage practice improvements and culture change among health care workers that will help prevent SSIs. Several evidence-based interventions designed to prevent SSIs have been identied and will be implemented in stages by DHBs over the next year.

Dr Sally Roberts
Clinical Lead, Infection Prevention and Control

Published in November 2013 by the Health Quality & Safety Commission, PO Box 25496, Wellington 6146. ISBN 978-0-478-38564-9 (print) ISBN 978-0-478-38563-2 (online) This document is available on the Health Quality & Safety Commission website at: www.hqsc.govt.nz.