Serious Adverse Event Report 2017

Adverse events need robust reporting culture

Reporting adverse events in a timely way to develop a robust reporting culture are integral to learning from the national Serious Adverse Events report, released today by the Health Quality and Safety Commission, (HQSC).

John Gommans Hawke’s Bay District Health Board’s Chief Medical and Dental Officer said, while Hawke’s Bay reported more cases this year, (13 -21) the number of adverse events remained rare with nearly 49,000 people presenting to Emergency Departments at Hawke’s Bay and Wairoa Hospitals last year and nearly 42,000 patients admitted to hospital.

“We welcome this annual Serious Adverse Events Report from HQSC as it plays a pivotal role to ensuring all patient safety events are reported promptly, properly investigated and learned from,” Dr Gommans said

 “Patient safety is our utmost priority, and to help build on the culture of reporting, in the past year the district health board has employed a dedicated patient safety advisor to work with a formal clinical review panel that reports to our Clinical Council.”

Dr Gommans said as part of reviewing where patient safety needed to improve, the district health board had recognised its radiology capacity needed to increase to improve access to scans and reduce diagnostic delays.

“An investment of nearly $4million in the past year, in staff and new equipment as well as extending MRI scanning to a seven day service, has been made and reduced delays to this critical service.”

 Dr Gommans said while work, such as improvements in radiology, was ongoing to make sure incidents were reported and remained rare, it was important not to minimise the huge impact adverse events had on patients, families and staff.

“We know it’s uncommon for an incident to occur and some are not preventable or are known complications of treatment.

“Medicine is not an exact science and we know we don’t get it right every time but we can only improve through learning, which is why nationally there is so much work happening to improve patient safety and outcomes and also internally within our own DHB.”    

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