The New Zealand Nurses Organisation (NZNO) questions whether the jump in serious adverse events last year is down to improved reporting or a lack of nurses.
A 21 per cent increase in serious adverse events (SAEs) was revealed in the 2012–13 report released in November by the Health Quality & Safety Commission.
A total of 489 events were reported by the 20 DHBs in that year compared with 360 events the previous year. Yet again the events were dominated by falls with 253 instances of serious harm from falls reported with 106 patients of the patients involved suffering a broken hip. The next highest category was 179 clinical management events, which included nine pressure injuries – up on one or two in previous years. For the first time, non-DHB providers, ranging from aged care facilities to primary health organisations and private hospitals, also voluntarily reported 52 events.
Professor Alan Merry said the overall increase in serious adverse events represented improved reporting and a greater willingness by the health and disability sector to learn from incidents. He said event reporting was about a culture of transparency and openness and he expected increases in reported events to continue in the next few years as reporting systems continue to improve, for example DHBs cross-checking events with ACC claims.
Kate Weston, NZNO professional nursing advisor, said the report is a good way of learning from mistakes. She said NZNO questioned whether 96 per cent increases in reported falls since the first annual report in 2009–10 could be just down to improved reporting.
“Staffing numbers just don’t add up,” says Weston. “The increase in nursing positions over the past four years is 4.4 per cent. Patient numbers have increased by 16 per cent – a fourfold deficit in nurses to patients. Sadly, this report shows the results of insufficient nursing staff.”
She said the report demonstrated that there must be the right number of skilled and qualified nursing staff on duty at all times to prevent patients dying or suffering a serious adverse event while in hospital.
“Our safe staffing campaign CarePoint is striving to ensure that DHBs do meet their obligations to keep both patients and staff safe.”
The Public Service Association said the reporting of serious incidents through a wider range of health providers should send a strong signal about the importance of the community sector in the delivery of health and disability services.
The Commission has also recently launched its national patient safety campaign Open for better care which was launched in May and initially focused on reducing falls and has now moved on to reducing harm from surgical site infections.
The full 2012-13 SAE report can be viewed at: www.hqsc.govt.nz
