Reporting on Serious Adverse Events

F_R_midcentral-healthEvery year all District Health Boards receive a summary of their adverse events which have been reported on.

During the period 1 July 21014 to 30 June 2015 MCH reported 20 serious adverse events which they reported to the health Quality and Safety Commission.

Each of the reported events involved a patient who suffered harm or death while in their care. MCDHB considers one such event to be one too many and they apologised unreservedly to the patients, family/whanau involved in these cases. MCDHB acknowledges the distress and grief which occurs for everyone when things go wrong. MidCentral Health works continuously to improve the quality of care that they provide.

MCDHB learns from these events and works to improve safety as a result. In order to do this they depend on events being reported by the people involved. A strong safety culture means that patients and their families, other health providers including GPs and nurses need to tell MCDHB when something has happened so they can be investigated and systems improved.

Continually strengthening the culture of patient safety and quality is a top priority for MCDHB. They are committed tp working with patients and families when things go wrong to ensure their concerns and needs are addressed and they are supported and included in the review process.

MCDHB openly communicates with patients and family at all times, including when adverse events occur, and acknowledge what has happened and to apologise immediately. They listen to concerns, provide support, involve patients and family as they prefer and where possible answer their questions and concerns.

When reviews result in recommendations for changes and action needed, MCDHB ensures these are implemented immediately.

The 20 reported events included 13 failures in clinical processes across a range of procedures and ages, 5 patient falls, 1 failure of equipment and 1 event involving patient behaviour.