Patient harm incidents decline

By Anne-Marie Emerson


More than 900 incidents of potential or actual patient harm occurred at Wanganui Hospital in 2011, according to a report recently released by the Whanganui District Health Board.

The report was prepared by the hospital's director of nursing and patient safety Sandy Blake and presented to a recent meeting of the Whanganui District Health Board.

The figures in the report showed that there were 902 clinical incidents at Wanganui Hospital in 2011. This figure is considerably less than the 2010 figure of more than 1000 incidents, and is on a par with the figure for 2009. There were more than 192,000 hospital visits in the 2011-12 year.

The five most significant types of incident included falls, medication errors, aggression, AWOL, and discharge planning.

There were 133 falls in 2011, of which 59 caused actual harm, and 96 medication errors, with seven of them causing harm.

However, in 2011 there were some shortfalls in the investigation procedures around serious incidents. The National Reportable Events policy specifies that investigations into serious incidents should be made within 70 days, and less serious incidents within 30 days.

The figures show that the average investigation time for serious incidents at Wanganui Hospital was 158 days, while 85 per cent of less serious incidents were reported within the required 30 days.

Ms Blake said in light of that, the Centre for Patient Safety and Quality undertook a review of the investigation process and found there was no close monitoring and a quality check process was not in place.

She said the centre was now offering technical expertise and time management advice to the investigation team to ensure the investigations are of a high standard.

She said she expected the timeframes would improve with the extra support and increased awareness of the issue.

Ms Blake said the hospital has 714 policies and procedures relating to patient care in place, of which 14 per cent were under review.

"Having current policies and procedures in place is an important component of patient safety. Staff are then clear regarding expectation of behaviour and standard of care," she said.

The report states there were 216 deaths at the hospital in the 2011-12 year. Four were stillborn babies, 17 were in the emergency department, 152 in the medical ward, one in mental health, one in obstetrics and gynaecology, eight in orthopaedics, and 33 in surgical.

Ms Blake said a review was carried out into each death, ideally within 30 days.

"The 30-day review process is met 45-55 per cent of the time. The months where the target is not met is when there is a higher than usual number of deaths."

Ms Blake said in 2010 the hospital began sending letters to the families of patients who had died in the hospital, expressing condolences and to let the family know a review of their loved one's death would be undertaken.

She said from these letters some families requested a meeting with hospital staff to discuss the care of their loved ones.

"Of the 320 letters sent from the start of the initiative in 2010 until the end of June 2012, less than 10 resulted in formal complaints.

"The fact that we have made the approach to the families, inviting them to tell us of any concerns meant that, going into the complaint investigation process, the family is more open to a positive resolution," Ms Blake said.

The report will be discussed further at a board meeting next year.

- WANGANUI CHRONICLE

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