Broken bones top list of adverse events in hospitals

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Broken bones from falls accounted for more than half of the 489 serious adverse events suffered by patients in hospitals and other health providers during the past 12 months.

The figures, released today by the Health Quality and Safety Commission, show of those serious events reported 82 patients died - though not necessarily the result of an adverse event.

Fractured hips were the highest events reported at 106, while other broken bones included 21 arms, 21 pelvises, and 14 femurs.

READ THE FULL REPORT ONLINE HERE

Head injuries from falls, drug overdoses, infections and transport and equipment-related events were also reported in the figures which showed a 21 per cent increase of incidents on last year.

It's the first of the serious adverse events (SAEs) reports to include events that happened at non-district health board providers, since reporting began in 2007.

These include private surgical hospitals, rest homes, hospices, disability services, ambulance services, primary health organisations, the national screening unit, and primary care providers.

Commission chairman Professor Alan Merry put the increase down to improved reporting and a greater willingness within the health and disability sector to learn from incidents.

"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 said.

Professor Merry said the increase showed a steady improvement in methods used to identify adverse events, rather than a sign the number of events themselves had been increasing.

"We expect increases in reported events to continue in the next few years as our reporting systems continue to improve. For example, DHBs are increasingly cross-checking their events with other sources of information, such as ACC claims."

Associate Minister of Health Jo Goodhew said it was only by reporting and reviewing events that health providers could find out what went wrong and change processes.

Mrs Goodhew said because falls continued to account for around half of all events, "reducing harm from falls" was the first issue highlighted by the Commission-led Open for Better Care campaign which was launched in May this year.

The campaign, being implemented by DHBs and other providers around the country, promoted use of evidence-based interventions to prevent falls and shared examples of initiatives around the country, she said.

"For example Waitemata DHB is having success with a range of initiatives including issuing non-slip socks and coloured wristbands to identify patients at risk of falling, as well as using lower beds for some patients."

SAE results for individual DHBs are on their websites while the full report is available on the Commission's website.