Falls prevention efforts are being praised for a 25 percent reduction in the number of Serious and Adverse Events (SAEs) reported in Canterbury this last financial year.
The Serious Adverse Events, a Health Quality and Safety Commission report, released today shows Canterbury DHB reported 43 SAEs between 1 July 2015 and 30 June 2016 – this is down from 58 SAEs reported the previous year.
The biggest improvement has been in the number of falls occurring in Canterbury hospitals. Twenty nine patients had a fall, resulting in serious harm, while an inpatient during the 2015-2016 year - compared to 40 the previous year.
David Meates, Canterbury DHB Chief Executive, says while the only acceptable number of falls in hospital is zero, it is good to see improvement in this area.
"It's fantastic to see the Canterbury's 'Whole of System approach to falls prevention' making gains."
Mr Meates says the DHB has been committed to achieving zero harm from falls since 2011, focusing on the three key areas - falls prevention in the wider community, falls prevention in rest homes and falls prevention for older people receiving care in our hospitals.
"The latest SAE report demonstrates that our efforts are making a difference," Mr Meates says.
"There continues to be a focus on identifying risk factors and tailoring falls prevention strategies to meet the needs of individual patients while they are in hospital and for when they return home."
He says the implementation of the electronic incident management system has also provided access to data used to identify trends and focus future improvement work.
While falls accounted for the majority of SAEs reported in Canterbury, Mr Meates says its vital all incidents continue to be reported and that staff feel safe doing so.
"Preventing adverse events relies on our continued efforts to review and learn from mistakes when they happen.
"It's important for staff to feel supported to speak up to improve what we're doing and learn from what went wrong
"Ensuring we remain transparent and have an open reporting culture is key to us being able to make the necessary changes to ensure the same thing doesn't happen again."
Mr Meates says when harm does occur, it's never easy for those involved.
"Our staff come to work every day with the aim of improving people's health. If a patient's condition deteriorates unexpectedly and suddenly, it can have a devastating effect," he says.
"We have an obligation to our patients, their family and whanau to be open and transparent and be honest about the care we've provided – even if it hasn't gone to plan."
In the community and rest homes:
Over the past year, the Canterbury Community Falls Prevention Programme provided care to over 1900 older people. Following an initial home visit from a physiotherapist or registered nurse, a home falls assessment and hazard check is completed, and a personal falls prevention programme is tailored to improve strength and balance and reduce the risk of falls.
A recent evaluation found that from February 2012 to February 2016 there have been 1,533 fewer people over 75 years presenting to the Christchurch Hospital Emergency Department due to a fall, compared with expected volumes based on pre intervention trends. The evaluation also found that there has been 455 fewer than expected admissions for hip fractures, 191 fewer deaths post hip fracture than predicted and 800 fewer bed days occupied in hospital per year due to a fall in the community.
The SAE reports can be accessed via the Health Quality and Safety Commission website: www.hqsc.govt.nz. Canterbury's can be viewed via the Canterbury DHB website: www.cdhb.health.nz
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