7/12/2018 8:38:58 a.m.

Friday 7 December 2018


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 that have resulted in a patient dying or suffering serious harm from using health and disability services.

This year there is a new category of event called an “Always Report and Review” event or ARR. These events may not have caused significant or any harm but could have and therefore must be reported and reviewed to the same standard as a serious adverse event.

Additionally, the Serious Adverse Events Report will include events affecting patients within Mental Health and Addictions Services (MH&AS). These events have previously been reported by the Director of Mental Health. Due to this change in the reporting, mental health events occurring from January 2017 to June 2018 will be included in this year’s release.

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 a total of 21 serious adverse events over the 2017/18 period:

• 12 general events (down one from 13 last year) and 2 ARR events (new category) - over 12 months: 
       10 related to clinical process (assessment, diagnosis, treatment and general care), included the 2 ARR events. Four of these events resulted in death. 
        3 Hospital Acquired Infections 
        1 Fall 
        13 events occurred in Rotorua, 1 in Taupo

• 7 Mental Health events all resulting in death (over a period of 18 months) 
        4 in Rotorua 
        2 Taupo 
        1 across both sites

A further two events were withdrawn since the HQSC cut-off date – one general, one MH&AS. Another event was downgraded from a serious adverse event but remains in the ARR category.

Improvements that have arisen as a result of these events include: 

1. The new falls assessment and care plan document that was in development last year has now been implemented. A network of falls link nurses in the wards has been set up and training provided with regular study days for these link nurses.

2. A change in protocol has occurred in Radiology for the detection of a particular diagnosis to align with international best practice.

3. New paediatric analgesia guideline has been developed and included in the medication safety training package for new house officers.

4. A Paediatric Early Warning Score education package has been developed and placed on the orientation programme for new house officers.

5. A change in the Radiology information system has occurred and the order of display of old and current films is now always consistent.

6. A print out of the most recent smear report logged with National Cervical Screening Programme is routinely made available on all women who attend the gynaecology clinic. This is now standard practice.

7. An information pack has now been developed for family/whānau of patients who die suddenly in hospital.

8. As a result of some of the mental health events, reviews of triage and multidisciplinary team processes are currently underway.

9. As of February 2018 there is a dedicated Crisis Assessment and Treatment Team based in Taupo for the Taupo-Turangi region.

Dr Sharon Kletchko, the Quality Risk and Clinical Governance Director says Lakes DHB very much regrets harm to patients and whānau as the result of our services.

“Reporting serious adverse events means we not only open up to our community about these events but the process enables us to go the next step, which is making sure it does not happen again. This is done through our engagement with our health professional staff and the adoption of improvements to the care we provide.”

Dr Kletchko adds that Lakes DHB staff care for their patients and population and are always open to learning and improving, that benefits patients and their whānau/family.


Fore more information about adverse events 2017-18 click here.