Two Hawke's Bay District Health Board (DHB) patients died after falls according to this year's Serious Adverse Events (SAE) Report.
Hawke's Bay recorded just 11 incidents in the Health Quality & Safety Commission report on District Health Boards, the same number as last year.
One patient died of natural causes and a Coroner's report is pending for the second death.
A review of the second death found that the patient, who died eight days after the fall, had a history of falls and suffered multiple medical conditions. A personal alarm had failed and there was no constant observation of the patient in place.
After a "delay in diagnosis" event it was recommended the DHB establish a hospital trauma committee. A review found unsatisfactory and/or missing documentation, an inadequate trauma survey and misdiagnosis, resulting in a care plan delay.
Last year nearly 40,000 people presented to Hawke's Bay Hospital's Emergency Department.
More than 33,000 people were admitted to hospital for treatment for elective surgery, maternity, as an arranged admission or as an acute admission through ED.
This year's SAE report also includes events reported by non-DHB providers including private surgical hospitals, rest homes, hospices, disability services, ambulance services, primary health organisations, the national screening unit and primary care providers.
Hawke's Bay Hospital's chief medical officer John Gommans said the Hawke's Bay health sector was embarking on a comprehensive Quality Improvement and Safety Framework "vision" that would improve patient safety.
"While this may not at times prevent tragedy from happening, it would work to help make sure patients were always at the centre of care and ensure health services were designed and set up within a quality and safety framework," he said. "This may seem common sense, and in most cases health services work seamlessly and effortlessly together, however sometimes because of the complexity, volume of presentations and number of health services involved links can occasionally be missed. This framework would work to provide a guide to make sure those links or themes weren't missed.
"While the 11 events reported represent significantly less than 1 in a thousand of all presentations to hospital, each of these events has a huge impact on patients, their families and the health professionals involved in their care.
"Every event is a tragedy and we don't underestimate that, but there are learnings from each event that will help us to build a more robust service and determine a better quality and safety vision for Hawke's Bay."
Nationally 489 serious adverse events were reported in 2012 - 437 by DHBs and 52 by other health providers. In 2011 there were 360.
The commission's chairman, Professor Alan Merry, said the increase in serious events represented improved reporting.
"This is about having a culture of transparency and openness in the health system, as any instance of harm to a patient is serious and should be reviewed," he says. "The increase in events reported since 2006-07, when reporting began, shows a steady improvement in methods used to identify adverse events, rather than a sign the number of events themselves have been increasing."