The latest Learning from adverse events report shows health providers in New Zealand are continuing to develop and improve their systems for reporting, reviewing and learning from adverse events.
Each year, health care adverse events are reported to the Health Quality & Safety Commission (the 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 happened and put in place systems to reduce the risk of recurrence.
Commission chair Professor Alan Merry says adverse events can have a devastating effect on the person involved and their family, whānau and friends.
‘Every event described here has a person at its centre. Adverse event reporting makes it possible to review each event, discover the reasons behind it and put recommendations in place with the aim of preventing anything like it from happening again.’
A total of 631 adverse events were reported by DHBs in 2017/18 (542 in 2016/17). The highest reported event category related to clinical management events. Other highlighted reporting categories include falls, healthcare associated infections and medication.
Professor Merry says the significant increase in reported events reflected the ever-increasing maturity of providers’ adverse event systems.
‘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. The 2017/18 year also saw the introduction of the always report and review list, which has increased reporting of near misses.’
For the first time since 2013, this year’s report also includes adverse events reported by the mental health and addiction (MHA) sector. A total of 232 MHA adverse events were reported by DHBs.
Professor Merry says the Commission will use this information in its MHA quality improvement programme.
‘One of the aims of the programme is to support providers to learn from and reduce serious adverse events. We will achieve this aim by providing guidelines and facilitating timely, consistent reporting and reviews. Improving consumer involvement in adverse events reviews and sharing findings are also important.’
The Ministry of Health endorses fully the Commission’s approach of learning from each adverse event.
‘The Commission’s efforts to reduce the harm from falls shows how its applied learning makes a difference,’ says Chief Medical Officer Dr Andrew Simpson.
‘Now, with the growing maturity of this reporting, we are seeing more complex problems requiring more cross-organisational work to address them. The Ministry will be working in conjunction with the Commission, ACC and DHBs to look at how best to do this.’
A copy of the full adverse events report is available below.
Along with its learning from adverse events programme, the Commission has a strong focus on improving patient safety across a range of areas, including infection prevention and control, medication safety, surgery and falls.
The Commission is also responsible for statutory mortality review committees, which have a significant role to play in reducing deaths in New Zealand.