Health Quality and Safety Commission report shows CDHB on track for zero harm from falls

Wednesday November 21, 2012

​A Health Quality and Safety Commission report shows Canterbury District Health Board is closer to achieving its goal of 'zero harm from falls'.

Today (November 21, 2012) the Health Quality and Safety Commission have released: Making Our Hospitals Safer, which summarises the Serious and Sentinel Events reported by all 20 District Health Boards from July 1, 2011 to June 30, 2012.

Dr Nigel Millar, CDHB Chief Medical Officer, says falls can cause significant harm to patients and can even result in death, which is why the CDHB has worked hard to reduce the number of falls happening in our hospitals and in the community.

"Every fall or any other type of serious adverse event that results in harm to a patient is something the health system always wishes to avoid.   There is no acceptable number of serious or sentinel adverse events.  These incidents occur when people are let down by the system, which exists to protect them," Dr Millar says

"Encouragingly we are starting to see evidence our efforts towards zero harm from falls is working.  In the past year serious harm from falls has reduced by more than 40%"

Falls reported in the HQSC report have reduced from 38 in the 2010-2011 financial year to 22 for the 2011-2012 year.

Dr Millar says while the results are encouraging, CDHB and the community shouldn't rest on its laurels.

"Achieving our goal of zero harm from falls, as well as preventing any sort of harm to patients both in a hospital or community setting, is going to take perseverance – not only from our staff but also from everyone – the responsibility is shared by us all."

Dr Millar says through reporting events and investigating the cause, CDHB is able to change the way it works and improve its systems and processes.

"The CDHB must always do everything possible to reduce the chance of the same thing happening to another patient. When people are harmed in our care we must respect their experience through being open and honest about what has happened." 

David Meates, CDHB chief executive says staff have always been encouraged to report all incidents, even 'near misses' so that measures can be put in place to minimise the chance of a similar incident in the future. 

"The system cannot improve if we don't learn from our mistakes. It's important we foster a culture where we continue to make adverse events visible so that we can continue to improve the standard and quality of care we provide."

"It's about having those difficult conversations. Apologising to patients and families when someone has been harmed or has died as a result of a failure in our ability to provide appropriate care is one of the toughest conversations a clinician or manager will have. But it's the least we can do."

Information on CDHB's sentinel events can be found here:


Information on the HSQC report can be found here:


Background information and frequently-asked questions

What is an incident?
An incident is any event that could have or did cause harm to a consumer (see adverse event, near miss, reportable event).

What is an adverse event?
An adverse event is an incident which results in harm to a consumer (see incident; near miss).

What is a near miss incident?
This is an incident which under different circumstances could have caused harm to a consumer but did not, and which is indistinguishable from an adverse event in all but outcome.

Serious and sentinel events are events which have generally resulted in harm to patients

A serious event is one which has led to significant additional treatment

A sentinel event is life threatening or has led to an unexpected death or major loss of function

Preventable describes an event that could have been anticipated and prepared for, but that occurs because of an error or some other system failure.

Root cause analysis (RCA) or RCA methodology is used to investigate an event to identify causes and contributing factors, and to recommend actions to prevent a recurrence.

What types of events were reported by Canterbury District Health Board?
There were a total of 48 serious and sentinel adverse events, the majority (22) were falls, with the remaining 26 described as 'clinical events' where there were errors or other problems with the care provided.

Why are falls so serious?
In older people in particular, a fall can result in a fracture or broken bone.  The flow-on effect of this can lead to lack of mobility which leads to lack of independence and these factors can combine to make other long-term or underlying health problems worse.

What is CDHB doing about the number of patient falls?
We are committed to 'Zero Harm' from falls and are 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 Canterbury DHB hospitals. Key focus areas over the past 12 months include:

  • Designing and funding a Community-based Falls Prevention Programme that suits the local context, including:
  • - A modified version of the Otago Exercise Programme - a 12 month in-home exercise programme for the frail elderly which is delivered by DHB funded 'Community Falls Champions' who are     either physiotherapists or nurses.  
    - The 'Stay on Your Feet' Programme where trained volunteers provide a community programme for more active older people (65+) either in their homes or in group settings.
  • Falls Prevention in aged residential care (rest homes)

Research suggests that Vitamin D supplementation for this group of older people significantly reduces falls and serious harm from falls. The Canterbury DHB is working in a collaborative way with rest homes and primary care providers to ensure that 75% of residents are receiving Vitamin D supplementation, through a Vitamin D Supplementation Programme in partnership with ACC.

  • Falls management in Canterbury DHB hospitals

The focus to date has been on raising awareness and reviewing what we currently do to help inform falls prevention strategies in our hospitals.  Two of the key projects this year include:

  • April Falls' Awareness Campaign
    This campaign is designed to raise the awareness of the importance of preventing falls, not only in our hospitals but across the community.  Information boards, a selection of posters and data       on falls in our hospitals were prominently displayed during April in all of our hospitals. 
  • Real Time Falls Study in Hospital Setting
    Recent findings from a Canterbury DHB hospital falls study reinforces the need to pay close attention to the specific falls risk for each elderly patient while they are in Canterbury DHB care.  In addition to addressing patient-specific factors, staff will undertake the following inpatient falls prevention actions (the essentials) if an older person is admitted to hospital:

1.    Ask if they have suffered a fall at home over the last 12 months
2.    Assess their  risk of falling in a hospital environment
3.    Ensure that appropriate falls risk management is in place for their hospital stay
4.    Discuss the findings and the prevention strategies with the person and the family

5.    Discuss with the person and their family falls prevention strategies for when they return home. This may involve referral to a Community Falls Champion. 

For more information about Canterbury DHB's falls reduction programme:


The report Making our Hospitals Safer can be viewed at

Page last reviewed: 24 July 2013