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This section contains media releases released a little while ago. Please note that due to the long time when some of these were released images have been removed and some links might no longer work.

November 21, 2013

Making Our Hospitals Safer

The reporting today of serious adverse events by the Health Quality & Safety Commission adds emphasis to a focus on the quality of patient care at the West Coast DHB says Chief Medical Officer Dr Carol Atmore, and reflects an improvement in incident reporting.

The Health Quality & Safety Commission New Zealand report ‘Making Our Hospitals Safer’ was released today. This is their seventh report on serious adverse events. The report can be accessed via the Health Quality and Safety Commission website .

There were ten serious adverse events reported by West Coast DHB for the 2012-2013 year compared to four last year, seven of which are currently under review by the DHB. West Coast events can be seen on the Serious Adverse Events page on this website

Dr Atmore says, “The increase in reporting has come about because of an improvement in culture of openness and transparency within the organisation, with staff more willing to report incidents so we can learn from them and take the necessary steps to prevent similar incidents occurring in future.

“The increase in our reporting of serious adverse events can also be attributed to improved reporting processes and the trust and confidence that staff have in our incident review system,” says Dr Atmore.

Dr Atmore says that four of the serious adverse events reported related to maternity services on the West Coast. “It is for this reason that earlier this year we commissioned a review of the DHB’s maternity services. The review team found that there were no recurring themes in either the incidents or root cause analysis investigations into the serious adverse events undertaken by the DHB. In fact the review team stated that ‘the increase in frequency of such events seems to be a positive manifestation of an evolving culture change with regard to the reporting and investigating of incidents and adverse outcomes’.”

Dr Atmore says the review team provided specific recommendations for improvements in the quality and sustainability of the West Coast’s maternity services which are being implemented.

“It is tragic for everyone in the public health system when a patient is harmed while receiving medical care. For patients, families and staff these events have huge impacts, so the incident reporting and investigating process that follows any incident is the key to reducing the likelihood of it recurring,” says Dr Atmore.

The West Coast DHB’s incident review system has four key stages. Recognising and reporting incidents and near-misses is the first stage. The second stage sees serious incidents reviewed by a team with recommendations made to address any system gaps identified. The third stage involves the investigation and its recommendations being reviewed by clinical leaders and senior management. From both reviews, further recommendations are made with the intention of reducing the likelihood of something similar happening again. The fourth and final stage involves key staff being tasked with implementing and monitoring the recommendations to ensure real change occurs.

Serious incidents are also reported to and monitored by the Health Quality & Safety Commission. It is their decision as to which events are reported publicly as part of their annual report.

David Meates, West Coast DHB Chief Executive says, “The reporting system on the West Coast underpins the organisation’s quality and patient safety processes. West Coasters can be assured that the reporting and investigation processes that occur, serve to make our hospitals safer and lessen the chance of future incidents.”


The Maternity Services review summary can be found by selecting the link below:


What is an adverse event?

These events were previously referred to as ‘serious and sentinel’ events.

An adverse event is any event not related to the natural course of a patient’s illness or underlying condition that has resulted in harm to a patient.

How is the seriousness of an event determined?

A Severity Assessment Code (SAC) Matrix is used to help ensure that the appropriate level of investigation is undertaken. Depending on the outcome of the event a code of 1-4 is assigned. The code determines the level and depth of investigation that occurs. Any incident scoring 1 or 2 is deemed to be serious and is notified to the Health Quality and Safety Commission. An example of this includes a patient who has a fall while in hospital and breaks a bone.


For more information please contact:

Erin Jamieson
Communications Team
m: 021 743 237
t: 03 769 7400
Corporate - West Coast District Health Board | Grey Base Hospital, PO Box 387, Greymouth 7840

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