Patient errors a chance to learn and reduce harm, says district health board

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Although people have come to harm at Hawke's Bay Hospital, the recording and investigation of serious adverse events are a way to improve patient care.
Although people have come to harm at Hawke's Bay Hospital, the recording and investigation of serious adverse events are a way to improve patient care.

Medication errors, falls, and a case of delayed treatment where a patient permanently lost their eyesight were some of the adverse events recorded by the Hawke's Bay DHB in the year to June 2016.

Hawke's Bay Hospital chief medical and dental officer Dr John Gommans said that although patients were harmed, it was only through learning from these events that the risk of others being harmed could be reduced.

From June 2015 to June 2016, two medication errors, four falls and injuries resulting in fractures, two cases of delayed diagnosis and two cases of delayed treatment were among those recorded in the HB DHB serious adverse event report.

In one case of delayed treatment, caused by a booking error by relieving staff, a patient suffered a "non-reversible loss of vision".

Four patients suffered bone fractures with causes ranging from being injured while being moved out of a scanner to slippery flooring.

In all there were 13 events, and each one impacted not only on the patients but also their families, Dr Gommans said.

"These events have ongoing consequences for those patients, their families and their experience with the health system. We have to make sure we always learn from the event and take actions to stop them happening to someone else."

Dr Gommans said all serious adverse events were investigated to determine the cause, or causes, but on the whole remained rare.

Each year more than 43,000 people present to the Emergency Department and 39,000 people are admitted to hospital in Hawke's Bay.

Dr Gommans said clinical teams were continually working together to improve the quality of patient care at Hawke's Bay Hospital.

"Improving how we communicate with patients and working to put patients at the centre of care is a real focus. We have also worked hard to prevent injuries from falls and have reduced the number of fractures by half in the last year."

Patient safety and quality improvement programmes were making a real difference, he added.

"We know we don't get it right every time, but we are improving by learning from events and working with our patients, their families and our staff to make sure we have a safe, supported environment for patient care."

- Hawkes Bay Today

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