Adverse events report signals stronger focus on learning from consumers

The latest Learning from adverse events report recommends putting consumers at the centre when reporting, reviewing and learning from adverse events.

Each year, health care adverse events are reported to the Health Quality & Safety Commission by district health boards (DHBs) and other health care providers. The Commission works with these providers to encourage an open culture of reporting, to learn from what happened and put in place systems to reduce the risk of recurrence.

A total of 542 adverse events were reported by DHBs in 2016–17 (520 in 2015–16). The highest reported event category related to clinical management events. Other highlighted reporting categories include falls, pressure injuries and healthcare associated infections.

Commission chair Professor Alan Merry says adverse events in health care can have a huge impact on the person involved and their whānau, family and friends.

"I would like to acknowledge the people affected by the tragic events outlined in this report. Partnering with consumers and whānau in the review and learning process is pivotal to improving quality and safety."

Prof Merry says research shows consumers who have been affected by an adverse event offer a unique perspective on that event. "Consumers may be able to perceive care transition and process issues, including service quality, that occur before, during and after adverse events, that are less likely to be identified by providers."

Prof Merry says the adverse events report reflects a steady improvement in reporting culture towards increased transparency and taking action based on learnings from system failings.

"The reporting process challenges traditional paradigms that some harm is a normal and accepted consequence of health care treatment. It focuses on insights and lessons learned, and identifies opportunities for intervention and improvement. For example, the 2015–16 report highlighted a rise in ophthalmology events. Since then there has been significant collaborative work undertaken in the sector in relation to the needs of people with chronic eye conditions."

Prof Merry says the rise in reported pressure injuries may reflect a concerted effort across the sector to raise awareness of the impact and devastating harm of those injuries. ‘This attention is particularly important given evidence shows pressure injuries are highly preventable.

"The category of healthcare associated infection has been highlighted this year, with an increase in additional reporting. This may reflect both an improvement in reporting culture and awareness-raising through the work the Commission and sector are doing as part of the Surgical Site Infection Improvement programme."

A copy of the full adverse events report is available here. See individual DHB websites for a breakdown of their figures.