Background

In late 2011, a project to map current activity in the health sector on falls and pressure injury prevention was initiated by the DHB Shared Services (DHBSS) Hospital Quality and Productivity Programme, with support from the Health Quality & Safety Commission (the Commission), the Ministry of Health Chief Nurse Business Unit (CNBU), Accident Compensation Commission (ACC) and other partnering organisations.

All 20 DHBs and a number of aged residential care (ARC) and other providers were surveyed, and the mapping report was delivered in March 2012.[1]

You can read the report here.

While many organisations had well developed programmes and reporting systems, findings overall were that:

• there is no standardisation or consistency in strategies used nationally, regionally or within districts
• there are no national indicators to measure actual harm, no cross sector reporting standards or systems, and many organisations are using paper-based reporting systems
• some organisations did not have the dedicated committee, high-level organisational oversight or key leader thought to be essential in effective implementation of programmes.

Additionally, the project established that falls and pressure injuries are identified internationally as ‘nurse sensitive indicators’.

Key recommendations were:

• to separate falls injury prevention and pressure area injury prevention as concurrent projects under a common governance
• that key stakeholders collaborate to direct the development of approaches, tools and resources which can be applied consistently at national, regional and local levels.

The mapping project’s findings and recommendation have informed the Commission’s response to the Minister of Health’s 2012/2013 Letter of Expectations, in which the Commission was asked to focus on reducing harm from falls (making it one of four priority areas along with surgical safety, medication safety and hospital-acquired infection). Specifically, the letter states expectations that the Commission will be:

• Setting targets in the area of falls reduction... and working with DHBs to ensure the early achievement of these targets – it will be important that a sector-wide view emerges on these issues – this will in turn increase understanding and ensure buy-in
• Continuing to provide evidence to underpin programmes and ensure the monitoring and evaluation of these programmes’ effectiveness....

[1] DHBs Hospital Quality and Productivity Programme Working Group (2012) A collaborative national approach to reducing preventable harm. Quality of care indicator mapping: Falls injury prevention and pressure injury prevention. Wellington: DHBs Hospital Quality and Productivity Programme.

Related Resources

• Resource: A Collaborative National Approach to Reducing Preventable Harm
  Reducing Harm from Falls