The annual summary of adverse events data from 2019/20 has been released by the Health Quality & Safety Commission.
Each year, serious health care adverse events are reported to the Commission by district health boards (DHBs) and other health care providers. A serious adverse event is one that results in serious harm or death. The Commission works with providers to encourage an open culture of reporting, to learn from what happened, and to put in place systems to reduce the risk of recurrence.
Between 1 July 2019 and 30 June 2020, a total of 975 (916 in 2018/19) serious adverse events were reported to the Commission. Of these, 627 were reported by DHBs (566 in 2018/19). Clinical management events continue to make up the majority of reported adverse events. This includes pressure injuries, delayed diagnosis or treatment, deterioration, and complications.
Dr David Hughes, clinical lead for the Commission’s adverse events programme, says that with lockdown and the ongoing COVID-19 response, this year has been extremely challenging for the health and disability sector.
‘Now more than ever, we must remain focused on the quality of our care and on keeping our patients and ourselves safe.’
He says event numbers are closely linked to reporting rates, and an increase doesn't necessarily mean more adverse events have occurred.
‘What it may in fact demonstrate is organisations continuing to develop an open culture where events are reported and learnt from, rather than an increase in preventable harm.’
Recently the Commission completed research into whānau Māori experiences of in-hospital adverse events, Ngā Taero a Kupe: Ngā wheako pānga kino ki ngā whānau Māori i rō hōhipera.
The research identified five major themes and two sub-themes from these experiences, including communication issues, perceived lack of care, lack of cultural safety and implicit bias.
Dr Hughes says that the insight gained from whānau Māori highlights the importance of putting the consumer and their families at the centre when responding to adverse events.
‘These events are not just numbers. As health care providers, we have a responsibility to listen to the experiences of consumers and their whānau, learn from what went wrong and work to prevent harm to others.’
Of the 975 reported adverse events:
- 627 were reported by DHBs
- 218 were reported from the mental health and addictions sector (DHBs only)
- 113 were reported by members of the NZ Private Surgical Hospitals Association (NZPSHA)
- 8 were reported by ambulance services
- 3 were reported from the primary sector
- 2 were reported from the aged care sector
- 2 were reported from a hospice
- 2 were reported by other providers
Of the 627 events reported by DHBs:
- 355 were clinical management events
- 231 were harm because of falls
- 20 were related to medication or IV fluid
- 13 were healthcare associated infections
- 4 were consumer accidents
- 3 were related to medical devices/equipment
- 1 was related to oxygen/gas vapour