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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.

October 30, 2014

Making Our Hospitals Safer

The Health Quality and Safety Commission New Zealand report 'Making Our Hospitals Safer' was released today. This is their eighth report on serious adverse events that have occurred in the country's hospitals in the past year. The report can be accessed via the Health Quality and Safety Commission website.

There were 12 serious adverse events for the West Coast DHB compared to 10 last year.

"Whilst we need to monitor any increase in events, this could be due to a more open and positive reporting culture," outgoing West Coast DHB Chief Medical Officer Dr Carol Atmore says.

"Last year the Health Quality and Safety Commission launched a 'falls initiative' and it could well be that the heightened awareness of falls resulted in more reporting (6 of the 12 incidents were related to falls). We are actively engaged in fall prevention and support the work of the West Coast Falls Coalition."

Dr Atmore stresses it is extremely important to be open and transparent when a patient is harmed while receiving medical care in the public health system.

"These events have huge impacts on our patients, their families and on staff. We've found that by encouraging the reporting and investigating process that follows any serious and adverse event, we are able to look at the way we do things, learn from it and reduce the likelihood of a recurrence," she says.

One such example has been the introduction of the ISBAR communication/handover tool across the DHB. ISBAR is an acronym that stands for; I = Identity, S = Situation, B = Background, A = Assessment, R = Request/Recommendation. The ISBAR tool helps improve communication between health professionals and enhances patient safety by reducing the risk of communication errors or omissions between staff. It also ensures handovers are succinct and timely, and that all relevant patient information is conveyed between staff.

The West Coast DHB (together with the four other DHBs in the South Island Alliance) is about to introduce a new Incident Management System. The new system will make it easier for staff to report incidents and lodge complaints to help improve patient safety outcomes.

"Our incident management system encourages a culture that recognises adverse events and incidents will happen from time to time. Through promoting a transparent and just culture of reporting and information sharing, staff will continue to learn and there will be on-going improvement of the quality of patient care," Dr Atmore says.

In a further effort to improve the management and response to adverse events when they happen, a new West Coast DHB Patient Safety Officer role is being established. This role will provide a single point of contact for patients and their families involved in serious and adverse events. The Safety Officer will maintain oversight on investigations following an event, to ensure that the learnings from the event, and feedback to families, are timely. Another initiative to assist in this process has been the provision of "Human Factors" training for WCDHB staff. This approach from an airline safety background aims to improve patient safety.

West Coast DHB Chief Executive David Meates says West Coasters can be assured that the reporting and investigation processes serve to make hospitals safer and lessen the chance of future incidents.

"It's important we take notice of these events to check for underlying systemic issues. Our internal systems are now working better in terms of identifying issues quickly and starting a process to address them. Ultimately, we want people to be able to have confidence that they will receive the healthcare they need from our health system and in the event that something does go wrong, it will be addressed in a timely and efficient manner."


Frequently Asked Question

What is a serious 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.

Why is the West Coast DHB ranked first in the serious adverse event league tables?

Our actual rate was 43.15 per 100,000 bed days, as we had 12 serious adverse events last year, not 13 as reported in the Health Quality and Safety Commission New Zealand report. When numbers are so small, 2 or 3 people make a huge difference to the rates. High reporting does not necessarily equal higher rates - reporting isn’t voluntary but you have to have an organisational culture where staff on the ground recognise and report serious adverse events. We have put a lot of effort in the last couple of years to changing how our staff view and approach serious adverse events. Although people don’t come to work to do the wrong thing, sometimes harm happens. When this happens our staff see the investigation process as a valuable tool to improve quality and to reduce the likelihood of a similar event in the future.

For more information please contact:

Lee Harris,
Senior Communications Advisor
West Coast District Health Board
t: +64 27 836 1528

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