Reducing harm from falls remains key focus for Canterbury Health System

Thursday October 30, 2014

A Health Quality and Safety Commission report shows Canterbury District Health Board remains committed to making its hospitals safer through transparent and open reporting of Serious Adverse Events.

Today (October 30, 2014) 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, 2013 to June 30, 2014.

In Canterbury there were 56 serious adverse events (CDHB) in the July 2013 to June 2014 year – up slightly on the previous year when there were a total of 47 Serious Adverse Events.

Dr Nigel Millar, Canterbury DHB Chief Medical Officer, says falls continue to dominate SAE's with 35 patients reported to have had a serious fall in our hospital in the 2013-2014 year.

"The Canterbury Health System continues to focus on making our hospitals and community care facilities safer to achieve zero harm from falls by 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," Dr Millar says.

In the community and rest homes the Canterbury Community Falls Prevention Programme, which enabled more than 3000 older people to be seen in their own homes, has been reviewed and improved.

"Clients will now have access to a more responsive, clinically- led falls programme, no matter their level of frailty.  All of these people will receive an initial visit including a home hazard check and the most appropriate falls prevention programme will then be delivered."

Dr Millar says the Canterbury DHB is also working with rest homes and primary care providers to ensure that at least 75 percent of residents over 65 years are receiving Vitamin D supplementation. 

"Research suggests Vitamin D supplementation for this group of older people significantly reduces falls and serious harm from falls."

In hospital the Canterbury DHB continues to focus on patient assessment and tailoring falls prevention strategies to meet the needs of individual patients while they are in hospital and for when they return home.

Dr Millar says in August 2013 a Steering Group was introduced to provide oversight and direction across hospitals for the Hospital Falls Prevention Programme.

"This programme aims to reduce falls in hospital and includes routine activities such as the annual Falls Awareness Campaign, reviewing policies, monitoring falls and patient's assessments as well as key projects."

Two current projects are:

  • Standardising the falls prevention visual cues across hospitals and care of patients following a fall.  Visual cues can be displayed at the patient's bedside, worn as a bracelet or tagged to patient equipment.  They indicate to family and staff at a glance the level of assistance a patient requires in moving about;

  • Ensuring patients have access to appropriate walking aids, this involves identifying the barriers to patients bringing their own walking aids to hospitals as well as looking at the availability of walking aids in hospital.

"At Canterbury DHB our patient focused, clinically led culture supports our commitment to 'zero harm' and continuous quality improvement. 

"All serious adverse events are reviewed through a formal process that involves a multidisciplinary team.  The purpose of reviewing these is to understand underlying causes of the event.  By identifying problems and failures we can learn from them and make our systems safer."

Frequently Asked Questions

What is an adverse event?
These events were previously referred to as 'serious and sentinel' events.  An adverse event is any event not related to the natural course of a patient's illness or underlying condition that has resulted in harm to a patient.

Read the Canterbury DHB Serious Adverse Event Report

Page last reviewed: 25 November 2014