Learning from Adverse Events report

21 Nov 2019, 13:22

Hawke’s Bay District Health Board reported 18 adverse events for the 2018-19 year. 

Chief Medical and Dental Officer Robin Whyman said although there were fewer events reported this year, compared to 24 the previous year, a number of priority areas had been identified for ongoing training and educating of staff to better manage deteriorating patients and pressure injuries. 

Dr Whyman said an early warning score system to identify patients quickly if they begin to deteriorate while they were in hospital had been put in place. The work is being led by senior clinical staff and we are pleased with the progress. 

In the past few years the district health board had also invested in more staff dedicated to reporting investigating and responding to patient events, he said. 

“We are always mindful, as we report these events each year, that there is a person and their family/whānau behind each of the numbers. The clinicians involved in these cases have a strong clinical interest to ensure each case is a learning and that there is transparency with the patient and their family during the process.” 

Dr Whyman said while there were 18 adverse events reported for Hawke’s Bay they should also be placed in context against the 33,256 people who were admitted to hospital, 51,129 who attended the emergency department and the 135,758 people who attended outpatient clinics in the 2018-19 year.