Making New Zealand Hospitals Safer

17 Nov 2010 | Adverse Events

New figures show New Zealand hospitals have a continuing focus on patient safety, says Professor Alan Merry, Chair of the Interim Board of the Health Quality & Safety Commission.

The Commission has released the 2009/2010 report of serious and sentinel events across the country’s District Health Boards (DHBs). A serious or sentinel event has, or has the potential to result in, serious lasting disability or death, not related to the natural course of the patient’s illness or underlying condition.

Professor Alan Merry says that in the 2009/2010 year, DHBs treated and discharged almost a million people.

“Of these, 374 people were involved in a serious or sentinel event that was actually or potentially preventable. Of those people, 127 died during admission or shortly afterwards, though not necessarily as a result of the event.  Half of these deaths occurred through suicide.

“These events are traumatic, and indeed often tragic, for the patients involved and their families, distressing for clinical staff, and costly for the health care system and society as a whole.  The human cost of these events is too high.

“While we cannot go back in time and prevent particular events described in this report, we can – and must – learn from them and reduce the likelihood of this kind of avoidable harm in the future.”

Falls (34 percent), clinical management problems (33 percent) and suicides (17 percent) were the three most commonly reported serious and sentinel events for 2009/2010. In the 2008/2009 year there were 308 reported events and 92 deaths, with falls, clinical management problems and suicides also the biggest categories. 

Professor Merry says the increase in reported events was anticipated and illustrates improved reporting processes in hospitals and a greater awareness of health and safety processes. 

“International experience with event reporting shows that the process of increasing awareness often results in a rise in the number of events reported.”

He says it is encouraging that many DHBs and private hospitals are introducing specific programmes and changes to make real improvements in patient safety.

Changes include: 

  • most DHBs, and a number of private hospitals, have adopted the World Health Organization’s Safe Surgery Checklist
  • many DHBs have instituted or improved comprehensive falls prevention programmes
  • booking and referral processes have been improved
  • a standardised medication chart is about to be introduced throughout New Zealand to reduce medication errors related to adult inpatients
  • a standardised process to reconcile medicines and reduce medication errors at the point of handover of patient care is planned for all DHBs and has already been adopted by some, and by some private hospitals.

Professor Merry is confident that everyone who serves New Zealand’s patients will be even more committed to ensuring safe and effective patient care, going into the future. 

“New Zealand has an excellent health system by international standards and the vast majority of patients are treated safely and effectively.  However, for a small number of people, preventable incidents occur.

“Learning from these incidents is essential if we are to continually improve the safety and quality of care provided by our hospital services."

For more information:

Liz Price, 0276 957 744, 04 527 3290


The Health Quality and Safety Commission

The Government created the independent Health Quality & Safety Commission to focus on quality and safety.  An interim Board has been established to allow this important work to begin, and the Commission will be formally established as a Crown entity in legislation by the end of 2010.

The Commission is responsible for assisting providers across the health and disability sector (public and private) to improve service safety and quality and therefore outcomes for all who use these services in New Zealand.

Last updated 20/02/2012