24/11/2017 12:06:47 p.m.

Friday 24 November 2017


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

Serious adverse events are those incidents which have resulted in a patient dying or suffering serious harm from using health and disability services.

While Lakes DHB endeavours to provide high quality services to its community, it acknowledges and sincerely regrets that at times harm occurs.

Lakes DHB has reported 13 serious adverse events over the 2016/17 period, two more than the 2015-16 year. These incidents were related to four categories of care: patient falls, medication, healthcare associated infection and clinical process (assessment, diagnosis, treatment and general care). All events occurred at Rotorua Hospital.

The 13 serious adverse events are:
• Four falls resulting in one death and three harms
• One hospital acquired infection
• One patient medication-related event resulting in death
• Seven patient clinical process related events. Of those, two events resulted in harm from misdiagnosis. Five events were related to maternity services clinical processes, resulting in three deaths and two harms.

Improvements that have arisen as a result of these events include:
1. A new falls assessment and care plan document has been developed. A network of falls link nurses in the wards has been set up and training provided.
2. Changes to the process and decision-making around replacement of the total knee joint liner during washout, due to infection. This recommendation was distributed to the orthopaedic surgical teams.
3. A national communication regarding interpretation of clinical guidelines was actioned, prompting a Medsafe review of medication safety datasheets, and standardised clinical protocols.
4. A plan to improve staff awareness of processes in place, particularly those relating to patients with limited English language proficiency.
5. Early recognition of diagnostic complexity to include low thresholds for early referral to tertiary specialty services.
6. Maternity antenatal clinic quality improvement project is underway ensuring streamlining of referral and documentation processes as well as identifying current and future resourcing requirements to optimise clinics capacity.

Dr Sharon Kletchko, Quality, Risk and Clinical Governance Director for Lakes DHB says the DHB has approved for clinical leaders a programme for “speaking up for safety and professional accountability which is an evidence-based framework that builds a high-performance culture of safety and reliability, and addresses individual behaviours that may undermine it”.

“This programme is part of Lakes DHB’s response to serious adverse events and our quest for zero preventable harm to our patients. Our DHB is taking positive steps with this programme to support our clinicians to do the right thing and to learn from these serious adverse events in terms of actions that should prevent these types of adverse events from recurring.”


Click here to view the full Health Quality & Safety Commission report on adverse events for the year ended 30 June 2017.