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BoP DHB - Serious and Sentinel Events

BoP DHB - Serious and Sentinel Events

21 Wednesday 2012

The Health Quality & Safety Commission has today released their November 2012 report titled Making Our Hospitals Safer.

Reporting Serious and Sentinel Events (SSEs) is an important step to improving health outcomes for New Zealanders.

In 2011/12 DHBs were asked by the Health Quality and Safety Commission to report all events, regardless of whether they were considered preventable. This is a significant change from previous years, where some DHBs reported only those SSEs which were considered to have a preventable element.

The Bay of Plenty District Health Board (BOPDHB) reported 11 falls in the year, of which four were deemed unpreventable. No other SSEs were reported in the BOPDHBs hospitals in Tauranga and Whakatane.

The BOPDHB is in the lowest percentile of Serious and Sentinel Events per 10,000 case-weighted discharges.

BOPDHB CEO Phil Cammish said his organisation works on the basis that no patient should be put at risk of falling, therefore the purpose of the BOPDHB falls prevention and management program is to:

• Initiate appropriate individual interventions and strategies directed to minimise the risk.
• Provide learning opportunities to patients, families and staff.
• Monitor, analyse and evaluate all patient falls and near misses.

“The impact on the patient and their families cannot be understated if a patient has a fall resulting in a fracture. Along with the personal costs, there are financial costs to the health system.”

Mr Cammish said the BOPDHB is pleased with the result and has programmes of work in place to ensure that there is further reduction in SSEs.

“While we know not all events are preventable, it is important to us and our patients that we keep risk to a minimum in our hospitals.”


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