HQSC report promotes transparency and learning from adverse events

4 December 2015

The Health, Quality & Safety Commission (HQSC) has released the ‘Learning from Adverse Events’ report today which has a greater emphasis on learning from all serious adverse events. 

Dr Greg Simmons, Taranaki DHB Chief Medical Advisor said, “Health care is demanding and Taranaki DHB staff do an excellent job at providing very competent and professional care to improve the health of our patients. Over the past year 29,618 people have been admitted and cared for at Taranaki Base and Hawera hospitals and the vast majority are treated without incident.”

“Everyone comes to work to do a good job, but sometimes, despite our best efforts, things do go wrong which is upsetting for everyone involved. The adverse event reporting process is about learning from our experiences and identifying system issues rather than finding an individual to blame.” Dr Simmons added.
This year’s report includes details of reported adverse events for Taranaki DHB but the names of patients, family/whanau and the individual clinicians involved remain anonymous. Some of the adverse events include falls , medication errors, delayed follow up appointments, and radiology related events.

Dr Ian Ternouth, Taranaki DHB Cardiologist said, “Adverse events are very distressing for patients and their family but also to the staff caring for them. ”

“Patients are now being offered treatment where several years ago they were not so we are seeing a lot more people who are really unwell, are older, have more complex conditions and so their complication rate will be higher. We always try our best and are saddened by an adverse outcome. They are taken very seriously by staff and when they do happen and the important thing is to learn from them,” said Dr Ternouth.

“Our staff are supported to recognise report and participate in the review of adverse events,” said Dr Simmons. “While it can be challenging and difficult for those involved, disclosure is a professional obligation and is an important part of patient centred care. It also reflects our open culture of reporting and transparency so that we can learn from what went wrong and put systems in place to make care even safer.”

Just this week Taranaki DHB introduced an electronic integrated incident, complaint and risk management system called Datix.

“This system will make it a lot easier to record adverse and near miss events and enable analysis and meaningful reporting at both a unit and organisational level. We’ll be able to look at trends, including the identification of issues and risks we need to address to increase safety and minimise adverse events,” said Dr Simmons.

Health Quality & Safety Commission:
Click here for the Health Quality & Safety Commission 'Learning from adverse events' (PDF 2MB)
Click here for Question and Answers - Learning from Adverse Events 2014/15
(PDF 368 KB)
Click here for the Health Quality & Safety Commission’s Media Release (PDF 89 KB)

Taranaki DHB:
Click here for Taranaki DHB Adverse Events results for 2014/15 (PDF 114 KB)



For more information please contact:
Cressida Gates-Thompson
Communications Manager
027 703 6177


Last updated: Monday, December 21, 2015

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