21/11/2019 12:08:09 p.m.

Thursday 21 November 2019


Lakes District Health Board (DHB) reports its Serious Adverse Events to the Health Quality and Safety Commission (HQSC) throughout the year. Once a year the HQSC and local DHBs report to their community a summary of these events. While Lakes DHB regrets any harm suffered by our patients, we strive to learn from these events to reduce the risk of further similar events and to improve the quality of care provided by our teams.

Serious adverse events are those incidents that have resulted in a patient dying or suffering serious harm from using health and disability services. Also reported are events known as “Always Report and Review” (ARR) events. These events may not have caused harm but are known to be likely to and so they must be reported and reviewed as if they were a Serious Adverse Event.

Lakes DHB has reported a total of 16 serious adverse events over the 2018/19 period:

• 6 general events and 2 ARR events:
      o 7 related to clinical process (assessment, diagnosis, treatment and general care), includes the 2 ARR  events. Three events resulted in death.
       o 1 Fall
       o 4 of these events relate to maternal/perinatal care
       o 6 events occurred in Rotorua, 2 in Taupo
• 8 Mental Health events 5 of which resulted in death:
       o 6 in Rotorua, 2 in Taupo

Adverse Event reporting is in two stages:

Part A informs the HQSC about the incident and applies a ‘Severity Assessment Code’ (SAC) rating to it.

Part B informs the HQSC as to the final rating of the incident, a summary of review findings, a list of review recommendations (if any) including any changes to systems and processes.

Of the 16 events reported by Lakes DHB, 13 have had “Part Bs” submitted to the HQSC. Three remain under review, i.e. they have not yet been completed so therefore not reported.

The national report makes mention of the under-representation of Māori in the reporting of these events. Lakes DHB has not undertaken statistical analysis of this at a local level due to the numbers being too small to be statistically meaningful, however of all events reported to HQSC, 11 involved NZ European patients, 4 involved Māori patients and 1 patient’s ethnicity was “unstated”.

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

1. A weekly combined diabetic/obstetric multidisciplinary team meeting is now established to discuss all the pregnant women with diabetes. These women are now seen in either one of two combined Diabetic Obstetric clinics with dedicated consistent doctors.

2. A new audit process is to be implemented for Radiology reporting. This is expected to be a recommendation that will take some time to complete for full implementation due to the technical requirements, however the department is actively progressing this work.

3. A review of the admissions process is underway for the MH inpatient unit outlining clear roles and responsibilities for different parts of the process and allowing for all specialties 24/7.

4. Dressing packs have been changed for packing wounds eliminating the use of multiple gauze dressings in the same wound.

5. The theatre teams have revised their checking procedure to ensure the whole team sights and verifies a prosthesis prior to opening and using it.

Click here to see the national report by HQSC about learning from adverse events for 2018-19