Serious Adverse Events 2013/14
21/10/2014 12:34:16 p.m.

Serious Adverse Events 2013/14


Every year DHBs report to their communities the serious adverse events that occurred during the year and were reported to the Health Quality and Safety Commission. 

Click here to see the full report of the Health Quality and Safety Commission which was released today. 

Serious adverse events are those incidents which have resulted in a patient dying or suffering serious harm from using health and disability services. Lakes DHB Quality and Risk Manager Lesley Yule says staff are mindful of the patients and families involved in these events and the DHB regrets any harm caused to patients during their care.

Reporting adverse events helps us to manage the risks of providing health care by identifying problems and failures in the system so we can learn and prevent similar events from happening.

Serious adverse events are reported following in depth investigations. 

Recommendations are monitored to ensure future risks are minimised. It is important to highlight the programmes we have developed as a direct result of serious adverse events and the subsequent investigations.

The process should give the Lakes DHB community confidence that we are transparent and open about serious adverse events and equally, that we are willing to learn from the mistakes.

Nationally in 2013/14 DHBs reported a total of 454 SAEs.

Lakes DHB results

Lakes DHB reported nine serious adverse events over the 2013/14 year.
Four of the events related to falls that caused serious harm.
The remaining five events were related to incorrect use of blood product, medication errors and/or issues with assessment, diagnosis, treatment and general care of a patient.

Due to the investigation recommendations, Lakes DHB made a range of improvements including:

• A new improved fluid balance chart.

Click here for more detail.

• Developed and maintained an on-going reduction in falls programme.

Click here for details of Lakes DHB's Falls Prevention programme. Click here for the falls prevention poster

• Commenced a major medication safety project.

Click here for medication safety storyboard. Click here for medication safety warfarin chart. 

• Improvements made for a safe and standardised clinical handover process across both hospitals.

Click here for detail of Safe and Standardised Clincial Handover (SBARR).

Quality and patient safety are a top priority for Lakes DHB. The on-going actions of staff are critical to patient safety. Click here for future plans for Quality and Safety at Lakes DHB.

Lakes DHB is committed to implementing the initiatives specified by the Health Quality and Safety Commission. All DHB staff, clinical leaders and managers are responsible for improving quality and participating in quality improvement initiatives and projects.

Click here for Quality and Safety Markers.