| 10 Nov 2016

Learning from Adverse Events

Today saw the release of the 2017-18 Learning From Adverse Events report which was published by the Health Quality and Safety Commission (HQSC).

Today saw the release of the 2017-18 Learning from Adverse Events report which was published by the Health Quality and Safety Commission (HQSC).

The report pulls together learnings from adverse events reported to the HQSC from all of New Zealand’s 20 District Health Boards and a number of other health care organisations.

This report highlights 8 such incidents at South Canterbury DHB in the area of Clinical Process (eg assessment, diagnosis, treatment, general care). This number is considerably lower than last year (20). Every event described here has a person at its centre. Adverse event reporting makes it possible to review each event, discover the reasons behind it and put recommendations in place with the aim of preventing anything like it from happening again.

It is extremely important to encourage the reporting of all adverse events so that we can learn from them and ensure procedures are in place to reduce the likelihood of further incidents in the future.

Over the last ten years South Canterbury DHB has been working with the HQSC to turn reporting into learning through rigorous investigation of adverse events and the identification of recommendations and actions.

Nigel Trainor CEO,  SCDHB said, “The emphasis on learning, not blame, ensures the healthcare team can be open, honest and focussed on improvements. Sharing this learning through the Adverse Events report builds a national database of good practise recommendations.

At South Canterbury DHB, the review of the Clinical Process / Procedure events has identified the need for us to focus our improvement activities on Early Warning Scores and the identification of patient deterioration, clinical handover processes between departments, and documentation of our plans of care.  We are pleased are to report that a new escalation pathway on early warning score has now been implemented at the DHB”

The number of serious adverse event falls across South Canterbury DHB was zero this year.  The implementation of the fall improvement programme 6 years ago has proved to be a critical programme that supports this figure.

- END –

Media contact:
Stacey Scott
Acting Communications Manager
South Canterbury District Health Board
P: 03 687 2395 | M: 021 688 588

Notes to Editor

The Learning From Adverse Events report can be found on the Health Quality and Safety Commission website: https://www.hqsc.govt.nz/our-programmes/adverse-events/publications-and-resources/publication/3580/

They also provide a Q&A which has been replicated below:

Learning from Adverse Events

reported to the Health Quality & Safety Commission 1 July 2017 to 30 June 2018

Questions and answers:
What is an adverse event?
An adverse event is an event with negative or unfavourable reactions or results that are unintended, unexpected or unplanned. In practice, this is most often understood as an event that results in, or has the potential to result in, harm to a consumer.1 Adverse events resulting in serious harm or death are reported by health and disability providers, guided by the Commission’s policy. This has been the first year of reporting using the National Adverse Events Reporting Policy 2017,2 which has a stronger focus on involving consumers and their families and whānau in the review process. The purpose of adverse events reporting is to understand the experience of the affected consumers, families and whānau to improve consumer safety, encourage open communication and learn from the events. The events in the Learning from adverse events report reflect local interpretation and implementation of the policy guidance by individual providers. It is important to remember that at the heart of the numbers are people, families and whānau who have been impacted by the event, as well as the health teams responsible for their care. The Commission views every adverse event in terms of that impact.
How many adverse events were there?
A total of 631 adverse events were reported by DHBs in 2017/18 (542 in 2016/17):
  • 317 clinical management events
  • 255 falls resulting in serious harm
  • 31 healthcare associated infections
  • 20 events related to medication or IV fluid
  • five consumer accidents (events that happen in a health care setting but are not related to the provision of health care)
  • three events due to medical devices or equipment.

In addition to the 631 adverse events reported by DHBs, the mental health and addiction sector (DHBs only) reported 232 adverse events.

Other providers reported 119 adverse events in 2017/18:

  • New Zealand Private Surgical Hospitals Association: 91
  • ambulance services: 18
  • primary care sector: one event
  • other providers: nine events
Why have mental health adverse events been included this year?
In the past, the Commission supported the Office of the Director of Mental Health to publicly report adverse events from the mental health and addiction (MHA) sector in its annual report. The Director’s annual report provided a broader mental health context for understanding MHA adverse events, which the Commission’s reporting did not provide. However, the Commission is now working more actively with the MHA sector through the national MHA quality improvement programme. A key priority of the programme is learning from adverse events.
How do providers notify the Commission about adverse events?
The Commission is notified in two stages: firstly, through a form that contains information setting out an initial understanding of the event, then through a second form at a later date, which contains a summary of review findings and recommendations. Some providers also submit anonymised copies of the full report. This allows the Commission to provide feedback on the quality of the review and gain more understanding of the event.
Are providers required to report?
DHBs are required to report adverse events to the Commission in accordance with the policy guidance. Some non-DHB health providers – such as private surgical hospitals, aged residential care facilities, disability services and hospices – voluntarily provide information.
How accurate is the adverse events data?
The Commission believes providers are increasingly recognising and reporting adverse events and that in some categories the number of reported adverse events is an increasingly accurate picture of the actual number of adverse events that occur. The number of broken hips in hospital reported by DHBs in this report, for instance, closely aligns with numbers included in the NMDS (National Minimum Dataset), which records information produced by public hospitals when a patient is discharged. Reporting in other areas is also improving, which reflects the quality improvement programmes being carried out by providers and the Commission. The adverse events reported reflect the evolving maturity of organisations to include broader types of events and to recognise the systemic influences contributing to their occurrence.
Is it possible to say exactly how many people died in 2017/18 as a direct result of an adverse event?
A total of 312 deaths were reported to the Commission in 2017/18. Of these deaths, 208 were suspected suicides reported from the MHA sector, and 104 were from across the rest of the health sector. However, these deaths were not necessarily directly related to the adverse event. How does New Zealand’s adverse events rate compare with those in other countries? It is difficult to gather accurate and comparable statistics on each country’s rate of adverse events, as different jurisdictions have different reporting criteria. The Commission believes that, based on local and international literature, the incidence of adverse events in New Zealand is comparable to other jurisdictions.
Is there an acceptable, or expected, number of adverse events?
International studies show 10–15 percent of hospital admissions can be associated with an adverse event, although about half of the events occurred before admission to hospital, in other health settings. In addition, some adverse events are known complications of treatment and are not preventable.
How safe is our health care system?
The standard of health care in New Zealand is generally high. In a typical year there are more than one million inpatient episodes in New Zealand public hospitals, and most people are treated safely and without incident. However, a small number of people are harmed while they receive care. Every adverse event represents someone who has suffered harm or has died in the care of the health system. People harmed by health care and their families and whānau can expect their case to be reviewed to understand what happened and what can be done to reduce the risk of the same thing happening again. Reporting adverse events is one part of a broader safety framework within New Zealand to make health care as safe as possible. Other measures and methods are required to demonstrate changes over time. These include reports and recommendations developed by the Commission’s mortality review committees, the Health and Disability Commissioner’s reports, Accident Compensation Corporation treatment injury reports, coronial findings and reports, and direct reporting from the Ministry of Health. The Commission publishes an annual window on quality that reports on the quality and safety of the health and disability system.
Shouldn’t health professionals be held accountable when things go wrong?
There are separate processes to hold clinical professionals accountable for the quality of their work and for maintaining professional standards throughout their careers. The reporting and review of adverse events aims to examine ways to improve health care systems by asking what happened, why it happened and what are the underlying causes. Reporting adverse events is about learning to make care safer by identifying system issues rather than finding an individual to blame. Is training in reviewing adverse events being offered? The Commission offers adverse event review training to all health and disability sector staff. The training is expected to improve capability in quality of reviews and development of effective recommendations and increase the pool of staff able to support adverse event reviews.
How does the Commission respond to emerging themes and issues from reporting?
Much of the information received by the Commission is based on initial notification information only, which limits the ability to offer detailed analysis because reviews take time to be completed and notified to the Commission. If too few reviews have been received by the Commission for events to be analysed in-depth, we continue to monitor the category and share relevant learnings. Those learnings then help prioritise improvement programmes. Emerging themes are used to inform quality improvement programmes within the Commission or passed on to the relevant bodies. It should be noted that work undertaken by the Commission and other agencies on focused programmes, training and current issues can drive reporting practice, for example, increased reporting of pressure injuries.
What action is being taken to prevent adverse events?
The Commission has a very strong focus on preventing adverse events and works closely with health and disability service providers to improve patient safety. This happens across a range of areas, including infection prevention and control, medication safety, surgery, falls, consumer engagement, mental health and addiction, and health measurement and evaluation. The Commission publishes Open Books, which help organisations learn from adverse events. In 2017/18 the Commission published three of these. The Commission is also responsible for statutory mortality review committees, which have a significant role to play in preventing harm.