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West Coast Serious Adverse Events 2017/18

Wednesday 12 December 2018Health news2 minutes to read

Patient supported by walking frame

Inpatient falls continue to be the major serious adverse event reported by West Coast DHB for the 2017/18 financial year.

The release of a Serious Adverse Events Report by each DHB is an initiative led by the Health Quality and Safety Commission. The reports highlight events which have resulted in significant additional treatment, major loss of function, are life threatening or have led to an unexpected death.

Of the 7 adverse events identified as serious by West Coast DHB, 3 were patients who had a fall while in hospital. The other 4 events were identified as readmission to ED 8 hours after discharge, delay in the detection of medical deterioration of an inpatient, inappropriate inter-hospital transfer and delay in 5-year colonoscopy surveillance.

West Coast DHB’s Medical Director Patient Safety and Outcomes Vicki Robertson says the West Coast Health System continues to make great progress in reducing the harm caused by falls but there is more preventative work to be done in this area.

“Falls can be very serious for patients whose health is fragile. We have a number of initiatives including thorough assessment of patient mobility needs in place as part of our Falls Prevention Service. We continue to be focused on reducing patient falls both in our health facilities and in the community,” Vicki says.

Nationwide, there was an increase in reported events, with the highest reported event category related to clinical management, including falls and pressure injuries.

As noted by Health Quality and Safety Commission Chair Professor Alan Merry, “several factors are 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.”

“Preventing adverse events relies on our continued efforts to review and learn from mistakes when they happen so that we can improve our systems and processes to make them safer,” says Vicki.


More information: West Coast DHB Serious Adverse Events Reports are available in our online Document Library.







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