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Reporting of adverse events enables improvements

For release 9.00am, Wednesday 20 February 2008

Reporting of adverse events enables improvements to patient safety at SDHB

Changes are made and new processes to improve patient safety are introduced at Southland District Health Board (SDHB) as a result of the voluntary reporting of serious or sentinel events and their investigation, said Chief Medical Officer Dr Pim Allen.

SDHB, which has over 280,000 patient contacts per annum, reported 17 potentially preventable serious and sentinel clinical events during the period 1 July 04 -30 June 07.

Dr Allen said that the summary report was released by SDHB today to provide the local community with transparency about events happening in the health sector.

"Adverse patient outcomes are happening in our health system. Many are the known complications of treatment and cannot be prevented, but some of these events are potentially avoidable and are therefore not acceptable.

"Such events are taken seriously by our staff. Most importantly, we take action to try and prevent the same outcome happening again.

"Modern healthcare is complex and despite the many safety checks at every stage of patient care, occasionally - and it is occasionally - things slip through all of the safety nets.

"What is vital is that we learn from these events and do not sweep them under the carpet."

Dr Allen said that encouraging staff to voluntarily report all incidents or identified risks was key to the organisation being able to continually improve patient safety.

"Investigating these events allows us to identify what we can do to try and prevent the same thing happening again.

"To do that, our staff must be supported to openly report incidents without there being a shame and blame culture," she said.

Dr Allen said that SDHB had stepped up its focus on quality and safety over recent time with a number of initiatives taking place, including regular external peer review through the accreditation process, staff education, policy review and the Board's recent initiation of a major clinical governance project late last year.

"We're also starting to share more information about these types of events with other DHBs so that we can all adopt recommended changes to prevent the same event taking place in our own organisation."

Dr Allen said that the Southland community had a right to expect safe, high quality health services from SDHB, and for the most part those expectations were met.

"Our staff and our Board are committed to further improving patient safety through a robust culture of continual quality improvement. We have some distance to go yet, but we are on our way," Dr Allen said.


Summary report available on from 9.00am, Wednesday 20 February.

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