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West Coast Serious Adverse Events 2018/19

Tuesday 26 November 2019Health news2 minutes to read

Inpatient falls continue to be the major serious adverse event reported by West Coast DHB for the 2018/19 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 3 adverse events identified as serious by West Coast DHB, all were patients who had a fall while in hospital.

West Coast DHB’s Medical Director Patient Safety and Outcomes Vicki Robertson says a lot of work has happened across the West Coast Health System to reduce the harm caused by falls but there is still more preventative work that we can do in this area.

“Falls can be very serious for patients whose health is fragile. As part of our falls prevention strategy, we work with our patients and their whānau to keep them safe while in hospital. We also have a number of initiatives including thorough assessment of patient mobility needs in place. We continue to be focused on reducing patient falls both in our health facilities and in the community,” Vicki says.

Nationwide, there was a reduction in reported events for the first time since 2011/12, with the highest reported event category related to clinical management, including falls and pressure injuries.

As noted by Health Quality & Safety Commission clinical lead for adverse events Dr David Hughes, “no one should experience preventable harm when they are receiving healthcare. The sector should work together to create a safety culture where people feel able to report harm without fear of being blamed for mistakes, and we can learn from what happened.”

“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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