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West Coast Serious Adverse Events 2019/20

Monday 14 December 2020Health news3 minutes to read

Inpatient falls continue to be the major serious adverse event reported by West Coast DHB for the 2019/20 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 5 adverse events identified as serious by West Coast DHB, 2 were patients who had a fall while in hospital.

West Coast DHB’s Chief Medical Officer Dr Graham Roper says a lot of work is happening across the West Coast Health System to ensure that there are continuous improvements made to the DHB’s systems and processes to reduce the harm caused by falls.

“Falls can be very serious for patients whose health is fragile. We have made good headway over the past few years with the implementation of a number of initiatives including thorough assessment of patient mobility as part of our falls prevention strategy. It’s really important that we continue to build on this work by remaining focused on reducing patient falls both in health facilities and in the community,” Dr Roper says.

Nationwide, there was a total of 975 reported events, with the highest reported event category related to clinical management.

As noted by Health Quality & Safety Commission clinical lead for adverse events Dr David Hughes, “event numbers are closely linked to reporting rates, and an increase doesn’t necessarily mean more adverse events have occurred. What it may in fact demonstrate is organisations continuing to develop an open culture where events are reported and learnt from, rather than an increase in preventable harm.”

Dr Roper agrees and says “West Coast DHB has robust incident reporting systems that allow staff to report adverse events.”

“While we aim for zero harm, having a strong incident reporting culture where staff are encouraged and supported to report adverse events enables timely review of the factors that contributed to these events.

“Preventing adverse events relies on our continued efforts to review and learn from mistakes when they happen. Its important staff feel supported to speak up so that we can improve what we’re doing, or learn from what went wrong as enables us to identify how we can improve our systems and processes to ensure the quality and safety of patient treatment and care is constantly improving,” says Dr Roper.


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


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Page last updated: 14 December 2020

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