Canterbury committed to improving patient journey

Thursday November 21, 2013

A Health Quality and Safety Commission report shows Canterbury District Health Board is committed to transparent and open reporting of Serious Adverse Events to people in its care.

Today (November 21, 2012) the Health Quality and Safety Commission have released: Making Our Hospitals Safer, which summarises the Serious and Adverse Events (SAE) reported by all 20 District Health Boards from July 1, 2012 to June 30, 2013.

The number of events reported by most DHBs has risen from the previous year, and this is believed to be the result of better reporting.

Canterbury DHB had 21 clinical management incidents or medication events plus 26 falls – a total of 47 Serious Adverse Events in the 2012-2013 financial year. This is slightly down on the previous financial year when Canterbury DHB reported 27 Serious and Adverse Events and 22 falls (49 events).

This is the Health Quality & Safety Commission's fourth report on SAEs, and the seventh report to be published since reporting on these events began.

However, it is the first report to include events reported by a number of non-DHB providers such as private surgical hospitals, rest-homes, hospices, disability services, ambulance services, primary health organisations, the national screening unit and primary care providers.

Dr Nigel Millar, Canterbury DHB Chief Medical Officer, says reporting events and investigating the cause helps the Canterbury Health System change the way it works to improve care provided to patients.

"Providing optimal care to the people of Canterbury is always the priority for the people who work in our health system," Dr Millar says.  

"However, there are known risks with many procedures, and we know there are additional risks for some groups of people when they are in hospital.

"Our job is to design systems that take this knowledge into account and minimise the risks.  Staff strive to do the best for their patients however, things sometimes go wrong. 

"When there is a serious adverse event for a person, it's vital that we do everything we can to see how it went wrong through being transparent and open around reviewing our processes so that it doesn't happen again and so we can minimise any further harm from occurring.

"In Canterbury we are developing a 'just' culture, which means it's ok to own up when things have gone wrong.  In fact, it's a clinician's responsibility to report serious adverse events and near misses' so we continue to learn and improve our systems following an adverse event."

Dr Millar says health professionals are skilled, motivated and committed to providing the best care possible for patients. 

"The reporting of SAEs is about learning from incidents that happen in order to prevent a recurrence, where possible. It is not about apportioning blame," Dr Nigel Millar says.

"Also the number or rate of reported SAEs is not a good way to judge a hospital's safety as a hospital reporting a larger number of events than others may have better systems in place for reviewing SAEs, more of a focus on safety, or provide a more complex range of health services."

To view Canterbury DHB's Serious Adverse Event report:

For more information contact Amy Milne 027 502 7523

Page last reviewed: 21 November 2013