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Serious Adverse Events Report 2012–13

Adverse events
21 November 2013

The Health Quality & Safety Commission has released the 2012–13 report of serious adverse events (SAEs) reported by district health boards (DHBs) and other health providers.

A total of 489 SAEs were reported in 2012–13 by DHBs (437 events) and other health providers (52 events). This compares with the 360 events reported in 2011–12 by DHBs, and represents a 21 percent increase in the number of events reported by DHBs.

This is the first report to include events reported by non-DHB providers. These include private surgical hospitals, rest homes, hospices, disability services, ambulance services, primary health organisations, the national screening unit, and primary care providers.

The Commission’s Chair, Professor Alan Merry, says the overall increase in serious adverse events represents improved reporting and a greater willingness within the health and disability sector to learn from incidents.

“This is about having a culture of transparency and openness in the health system, as any instance of harm to a patient is serious and should be reviewed,” he says. “The increase in events reported since 2006–07, when reporting began, shows a steady improvement in methods used to identify adverse events, rather than a sign the number of events themselves have been increasing.

“We expect increases in reported events to continue in the next few years as our reporting systems continue to improve.  For example, DHBs are increasingly cross-checking their events with other sources of information, such as ACC claims.”

Adverse events reported for 2012–13 include:

  • 253 instances of serious harm from falls, comprising 52 percent of all SAEs. Of these, 106 patients suffered a fractured neck of femur (broken hip)
  • 179 clinical management events, including delays in treatment, concerns about the accuracy of diagnoses, inadequate patient monitoring in hospital, and near misses
  • 24 medication events, with 11 of these related to administration of an incorrectly prescribed drug or drug dose.

Events affecting people using DHB mental health and addiction services were reported separately by the Commission in September 2013, and are not included in this report.

Dr David Sage, Clinical Lead for the Commission’s adverse events prevention programme, says accurate information and analysis helps the health sector understand the extent and type of patient harm occurring.

“Health and disability service providers – hospitals and others – need this information so systems and processes can be improved, to reduce patient harm,” he says. 

Sharing experiences, insights and innovations is a key focus of the Commission-led national patient safety campaign, Open for better care, which was launched in May this year.  The campaign is being implemented by DHBs and other providers around New Zealand, and focuses on reducing harm from falls, healthcare associated infections, perioperative care, and medication.

SAE results for individual DHBs are posted on DHB websites. The following are available: full report, summary document, and questions and answers.

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