Falls continue to dominate the latest serious and sentinel events report for New Zealand’s public hospitals.
Just over 50 per cent of the 377 events reported by the country’s 20 district health boards were falls (195). The Health Quality and Safety Commission said the reporting of falls had driven the overall increase in serious and sentinel events since 2007–2008 (just 56 falls reported), with no other event growing at a similar rate.
Kate Weston, quality spokesperson for the New Zealand Nurses Organistion, said the increase in falls was concerning as falls were a direct result of not having enough adequately skilled nursing staff on the floor to manage falls risk.
She NZNO would be monitoring fall trends as it was “imperative there were enough nurses on the floor to meet patients’ needs”.
The second most reported serious or sentinel event was errors of diagnosis and treatment (108 events or 29 per cent) with the third largest category being medication errors (25 incidents).
The commission said addressing medication errors was a priority and 15 boards had begun using a national medication chart for adult patients. A paediatric chart and a proposal for piloting a chart for the aged care sector were in development.
86 of the patients involved in the 377 reported events died, but not necessarily as a result of the adverse event itself.
Commission chair Alan Merry said the report was not about apportioning blame but improving the quality and safety of health services.
The commission also said DHB reporting of events was voluntary and recognised that DHBs reporting the “most events in the greatest detail” may have better reporting systems and “perhaps a superior safety culture”.
Likewise, a low rate of reported events may indicate “under-reporting and under-investigation of matters that go wrong” or “conversely may reflect the outcome of a very sucessful risk management programme or a combination of both”.
