21 November 2012

The New Zealand Medical Association welcomes today’s release of the Health Quality and Safety Commission’s 2011/2012 report into serious and sentinel events in District Health Board hospitals.

"This report will help the New Zealand health sector work towards reducing harm from preventable adverse incidents," said NZMA Deputy Chair Dr Mark Peterson.

"With almost three million people treated in public hospitals or as outpatients each year, the number of patients suffering serious or sentinel events is thankfully very tiny. But we must remember that these are not just statistics – each of these cases involves real people with families."

Dr Peterson said the important outcome from the report was to learn from what has happened and use this information to enhance patient safety. "DHBs and hospitals will need to look carefully at this report to determine if there are improvements which can be made to the way they do things."

"We are pleased to note that the Health Quality and Safety Commission will be writing to all DHBs to ask what changes have been made as a result of this report, and will publicly report on their responses."

He said it was important to remember that, above all, New Zealand has an excellent health system by international standards and harm to patients is extremely rare.

The report shows 360 cases of serious and sentinel events were reported, 3 percent fewer than the previous year.

Adverse events reported include:

  • A 13 percent decrease in falls from the previous year. Falls represent nearly half of all serious and sentinel events reported.
  • A slight increase in clinical management events, which represent just under one third of all incidents reported, and include an increased number of cases of delayed treatment due to failures in hospital systems.
  • A reduced number of medication errors.
  • A large increase in suspected in-patient suicides.