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MDHB releases information on 20 adverse events

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4/12/2015
MidCentral District Health Board today released summary details of 20 adverse events, as part of a national release of information through the Health Quality and Safety Commission.

The events cover the year 1 July 2014 to 30 June 2015, and are three more than last year. Nationally there were 525 events – 182 more than last year - the increase is largely a result of better reporting.
An adverse event is an incident that results in harm to people using health and disability services. Adverse events are reported by health and disability providers guided by the Commission’s national reportable events policy, and in general are those incidents that have resulted in a patient dying or suffering serious harm. 

NB: This report excludes unexpected deaths within mental health and addiction services, in line with national reporting arrangements. Such deaths are reported separately by the Director of Mental Health, Ministry of Health.  

Chief Executive Kath Cook and Chief Medical Officer Dr Kenneth Clark said: “We review and investigate every adverse event to identify the root cause so that we can ensure systems are put in place and aim to prevent a similar event happening again. We have a Serious Adverse Events Governance Group that co-ordinates and ensures all processes and systems in relation to investigations, learnings and recommendations, are robust.”

Nationally, the majority of events reported were for patient falls – 277 events, however there has been a national decrease in the number of fractured neck of femur (broken hip) cases. “At MDHB there were five falls resulting in a fracture (none resulting in broken hips), down from nine last year. We believe a concerted effort to sustain a falls aware programme, including low beds for appropriately assessed patients, and falls aware wards, has contributed to the lower numbers at MDHB.

“The majority of MDHB’s events were in the area of ‘clinical process’ – (assessment, diagnosis, treatment and general care of patients). There were 13 events at MDHB compared with 205 nationally.

“As with all events nationally there were a range of ages from babies to elderly. Four babies that died during the period are part of an independent review of maternity services that has been held, to see if there are opportunities for systems and process improvements. A decision on the outcome of that review is expected to be finalised in early February. A further two MDHB patients in this category are some of 27 patients nationally that the Commission is looking at further in its annual report, identified as ‘deteriorating patients’ – the events generally being as a result of poor communication.”

Commission chair Professor Alan Merry said a special focus this year will be on learning from cases where there has been a delay in recognition or a lack of recognition of a patient’s deteriorating condition.

“Deterioration can happen at any time in a patient’s illness, but patients are especially vulnerable after surgery and when they are recovering from a very serious illness. Recognising and responding to this deterioration quickly is important to avoid cardiac arrest or admission to an intensive care unit.”

MDHB’s other reported events were one each for: behaviour (a patient dislocated a shoulder as a result of unpredictable behaviour); and ‘medical device/equipment’ (where surgery was stopped because a piece of equipment failed and a backup piece was unavailable).
Details of MDHB’s summary of adverse events are on the MDHB website.

More information regarding adverse event reporting in New Zealand can be accessed from the Health Quality and Safety Commission website: www.hqsc.govt.nz


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