Tairawhiti DHB has 'obligation' to learn from experience

21 Nov 2013 | Adverse Events

Tairawhiti District Health has made changes to its falls assessment and care planning processes following investigations into four serious adverse events in the 2012/2013 financial year, one fewer than the previous year.

Following the release of the Health Quality & Safety Commission’s annual report on serious and sentinel events, TDH Chief Executive Jim Green said all four events were awful for the families and individuals involved.

“Unfortunately things sometimes do go wrong in healthcare – about 10 percent of inpatients, worldwide, experience an adverse event during their hospital stay. Unexpected complications of treatment happen and are often unavoidable however we also know that many are avoidable. As humans are prone to error we need to make all our systems and processes as safe as possible.

“As a district health board we have an obligation to learn from experience when things go wrong… and to use what we learn to improve safety and quality.”

Mr Green said staff reviews of clinical care, as well as incidents and adverse events, while sometimes tragic for the individuals and families involved, provide lessons, information, and the chance to promote change and best practice.

“In these four cases we have made every effort to find out the root causes and apply our learning to the areas where they have occurred.”

As a result of the events noted in the report, Tairawhiti District Health has made a number of changes.

The four incidents reported were:

  1. Patient discharged with the wrong medicines resulting in readmission
  • Clinical Nurse Manager highlighting the incident with all ward staff and reminded them of the importance of checking medicines when returning any brought in by the patient
  • A case study was performed and this was presented to the nurse and midwifery leaders meeting and to Clinical Board
  • The chief pharmacist is looking at implementing a discharge medication check list.
  1. Patient fell shortly after admission and sustained a fractured arm. Recommendations include:
  • Falls assessment, care planning and implementation to be completed within the same shift the patient is admitted.
  • The risk status of all new patients admitted to be handed over to the following shift.
  • Review the handover process to ensure that patients who need supervision are supervised during handover.
  • On-going education of all relevant staff regarding falls prevention. This education is now mandatory at Gisborne Hospital.
  1. Infant fell from trolley and sustained a fractured skull. Recommendations include:
  • Having cots in every cubicle for infants under 2 years of age.
  • Calling for a cot at time of triage if infant under 2 years of age is going to be admitted to ward by GP referral.
  • If there is a need to use an adult bed for any infant under 2 years old with a Triage score of 3–5, make sure that the parent/caregiver is aware of where to place infant on bed safely.
  • Take into account the Triage score and development age of the infant to decide whether to use a bed or cot. (All infants under 2 years of age.)
  • Minimise waiting times for GP referral of children for admission to Planet Sunshine after hours by reviewing the current Paediatric After Hours Admission and Emergency Department Triage Policy.
  1. Patient fell on the ward having been admitted after sustaining a fall. Following the first and subsequent falls computed tomography (CT) scan showed subdural haemorrhage. It is unclear if this precipitated or was subsequent to the falls. Recommendations include:
  • Reviewing the way in which staff take breaks to ensure patient safety.
  • Implementing ‘patient status at a glance’ charts to easily identify patients who need assistance with mobility.
  • Reviewing the way in which information is transferred between shifts.
  • Implementing best practices that evolve from the Open for better care regarding falls prevention.

Last updated 21/11/2013