Posted 10th Nov 2016 in Adverse Events

Figures in the latest Learning from adverse events report show a notable increase in ophthalmology events reported in 2015–16.

Each year, health care adverse events are reported to the Health Quality & Safety Commission by district health boards (DHBs) and other health care providers. The Commission works with these providers to encourage an open culture of reporting, to learn from what went wrong and put in place systems to reduce the risk of incidents recurring.

In 2015–16:

  • 520 adverse events were reported to the Commission by DHBs (525 in 2014–15) and 154 by other providers
  • clinical management events were the most frequently reported by DHBs, with 245 incidents (47 percent), including those relating to delays in treatment, assessment, diagnosis, observation and monitoring (including patient deterioration). Ophthalmology events fall into this category
  • serious harm from falls events were the next most reported, with 237 incidents (46 percent). Of these, 84 resulted in the patient suffering a broken hip
  • medication-related events were the third most reported, with 21 incidents (4 percent).

Commission Chair Professor Alan Merry says each of these very sad incidents has affected a patient, their family and whānau, and the health professionals who care for them.

‘While it is too late to prevent these particular events, we owe it to those affected to take a thorough look at what went wrong, so we can continue to improve systems and make care safer.’

This year, 44 events relating to ophthalmology were reported. These include delays in people getting follow-up appointments to see ophthalmologists, and in some cases eye conditions deteriorated.

‘This year, Southern and Nelson Marlborough DHBs both reported a number of individual ophthalmology events, including a delay in follow-up appointments. The Commission commends these DHBs for showing leadership in this reporting. These DHBs are currently reviewing these events, and will make improvements based on the findings,’ says Professor Merry.

‘This is a prompt for other DHBs to look closely at their ophthalmology services to ensure people are being seen in a timely manner, with high-risk patients prioritised. We anticipate more of these events will be reported next year, as DHBs focus on improving reporting in this area.’

The report shows a decrease in serious falls in public hospitals, from 277 last year to 237 for 2015–16 (a reduction of 14 percent). The decline is also reflected in the National Minimum Dataset, so is likely to be an actual drop, not a drop related to decreased reporting.

Dr Iwona Stolarek, clinical lead for the Commission’s adverse events learning programme, says this very pleasing result reflects the hard work of DHBs and other providers.

‘For example, involving patients and their families and whānau in falls risk assessments when an older person enters hospital can reduce falls. Having safe footwear, an uncluttered ward, and the appropriate and safe use of walking equipment are also important.’

A copy of the full report is available below. See individual DHB websites for a breakdown of their figures.

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