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.
- 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
How many cases of potentially preventable injuries and deaths have occurred in DHB hospitals nationwide?
For the 2009/2010 year, District Health Boards (DHBs) reported that 374 people had been involved in a serious or sentinel event that was actually or potentially preventable. That’s 0.037 percent (3.7 in 10,000) of total admissions.
In real figures, for the 2009/2010 year, 998,390 people were treated and discharged by hospital staff – 391,265 day patients and 607,125 inpatients. There were also over 1.7 million outpatient discharges.
Of the 374 reported cases, 127 people died during admission or shortly afterwards, though not necessarily as a result of the event. Half (64) of these deaths occurred through suicide.
In the 2008/2009 year, DHBs reported that 308 people treated in their hospitals were involved in a serious or sentinel event, and 92 died.
What is the expected number of events?
International studies show 10 to 15 percent of hospital admissions can be associated with an adverse event – although about half of the adverse events occurred prior to admission, in settings such as GP clinics and private hospitals. Many of the events are known complications of treatment and are not preventable with current knowledge. A very small number are serious and potentially preventable.
What is an acceptable level of risk?
Modern health care is complex, with powerful drugs and many highly trained professionals involved in treatment that can achieve astonishing results. With all of this comes the increased risk of human error, which is why we include sophisticated systems for checking safety. Considering the large numbers of patients treated successfully every day, it is rare for an incident to happen – or nearly happen.
It is the same in other high risk industries, such as aviation. Health is learning to apply techniques and lessons from these other industries to investigate such events, learn from the causes and reduce risk in future.
How can an increase in reported serious or sentinel events be a positive?
The increase is in the number of those events that have been recognised and reported this year as having potentially preventable element(s). Deaths from all causes, potentially preventable and otherwise, are reviewed in hospitals as part of routine clinical audit.
We believe the increase is due to the fact that we are getting better in recognising and reporting, rather than an increase in the number of preventable event(s). If anything, the increase shows a greater awareness of safety and quality improvement and that medical staff have growing confidence in the system.
What do these figures say about New Zealand’s health system?
New Zealand has an excellent health system by international standards and the vast majority of patients are treated safely and effectively. However, as is the case all over the world, for a small number of people, events happen that have the potential to cause harm or cause actual harm.
Any preventable serious harm to a patient is a tragedy. Learning from these incidents is essential if we are to continually improve the safety and quality of care provided by our hospital services.
What safety improvements have been implemented as a result of learnings from previous reports?
DHBs and other providers have introduced changes to make real improvements in patient safety in response to reporting in previous years.
- 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
- clinical management has been improved in a number of ways, including through the adoption of early warning systems to detect deterioration in a patient’s condition in time to begin treatment
- improved booking and referral processes
- a standardised medication chart is about to be introduced to reduce medication errors in relation to adult inpatients throughout New Zealand
- 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.
What are the main types of preventable serious or sentinel incidents?
Falls (34 percent), clinical management problems (33 percent) and suicides (17 percent) were the three most commonly reported serious and sentinel events for 2009/10. These were also the biggest categories for serious and sentinel events reported for 2008/09.
The report shows a number of recurring themes including, but not confined to:
- failure to recognise clinical deterioration in patients; underestimating the severity of a patient’s condition; and a lack of supervision of junior staff, or less experienced staff, by senior colleagues
- medication errors, including mistakes arising from illegible prescriptions and from failures to question incorrect doses, even when they seem exceptionally high or low, and the dispensing of medication by inexperienced staff
- poor communication, including inadequate handover processes, unclear processes and guidelines, and lack of proper orientation for new staff
- failures in referral and recall processes, resulting in delayed diagnosis and delayed treatment, leading to increased patient morbidity or death
- inadequate staff knowledge of and adherence to written policies and treatment guidelines, highlighting the need for more effective staff education, clearer documentation and more effective supervision
- inappropriate staff mix on ‘acute’ wards and units.
There is a big difference in the number of reported cases between some DHBs. Does this mean some hospitals are safer than others?
The number of incidents is not an indicator of a hospital’s safety – a large number of incident reports is also a sign of a high safety focus amongst staff. Larger specialist hospitals will also have bigger numbers because they see more patients and deal with more complex cases. Conversely, a low number of reported cases may reflect the outcome of a very successful risk management programme.
Different reporting rates between hospitals are also likely due to different approaches to how incidents are reported and recorded – the work we’re doing now, which is happening all over the world, is trying to get a consistent approach so we have good information to learn from.
Shouldn’t people be held accountable when things go wrong?
They are. There are separate processes that hold clinical professionals accountable for the quality of their work and maintaining professional standards. The reporting of incidents is about continually looking at our systems and the ways we can improve them to minimise the risk to patients in the future.