Learning from Adverse Events report

Hawke’s Bay District Health Board is committed to patient safety and the delivery of high quality patient care.

Chief Medical and Dental Officer John Gommans said this year’s learning from the Adverse Events report signalled a growing maturity and commitment district health boards had to patient safety and ensuring adverse events were captured, investigated and reported. 

Dr Gommans said the 24 adverse events reported for Hawke’s Bay for the 2017-18 year should be placed in context against the 32,202 people who were admitted to hospital, 46,400 who attended the Emergency Department and the 138,744 people who attended outpatient clinics. 

“There has been substantive efforts to make sure patient safety is our priority and that we minimise errors and avoidable harm; learn from the errors that do occur; and build a culture of safety where staff are committed to reporting concerns. 

“In the past two years the district health board has invested in more staff dedicated to improving patient safety. Nursing staff numbers have also increased substantially over the past year, which provided more resources for the assessment and care of patients,” he said. 

Dr Gommans said that people and whānau affected were now more actively engaged in the event review process. “While the focus of the event review is to better understand how to prevent harm occurring it also provided patients and their families with an opportunity to raise additional concerns regarding other aspects of their care.” 

Learning from these wider concerns was coordinated by the Consumer Experience Team, which was helping the district health board to understand what it could do better, what it did well and what it should do more of. 

“We know we don’t always get it right, but we do learn from our mistakes. We support the work of the Health Quality and Safety Commission and use the annual release of the Learning from Adverse Events report to learn from other district health boards,” Dr Gommans said.

Adverse Events Report 2017

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