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Zero Harm From Falls – the Goal for Canterbury DHB


February 20, 2012

Today (February 20, 2012) the Health Quality and Safety Commission released its report: Making our hospitals safer, which summarises the Serious and Sentinel Events reported by all 20 District Health Boards from July 1, 2010 to June 30, 2011.

In Canterbury there was almost one serious incident of some kind reported every week during the period being reported on. In total there were forty nine patients and their families who suffered in some way. The majority of incidents recorded were falls.

Dr Nigel Millar, Canterbury District Health Board (CDHB) chief medical officer, says every 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.

“When people are harmed in our care we must respect their experience through being open and honest about what has happened. It is through reporting events and investigating the cause that we can change the way we work and improve our systems and processes.The CDHB needs to do everything possible to reduce the chance of the same thing happening to another patient.

“It is very humbling when we talk to patients and their families after they have had a bad experience. They are universal in their desire for the knowledge gained from their experience to be used to change the system that let them down.

“Our responsibility is to continue to learn as much as possible about the circumstances that led to each preventable incident and to put systems in place to prevent a recurrence.

“To achieve this we investigate all serious and sentinel adverse events and will always inform the patient and their families of our findings and the resulting recommendations for change.

“Our staff are encouraged and supported to be open and honest in their communication with patients and families. 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,” Dr Millar says.

David Meates, CDHB chief executive says the CDHB has always encouraged staff 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.

“If we don’t learn from our mistakes or near misses the system won’t improve. We have developed a culture where we continue to make events visible so that we can continue to improve the standard and quality of care that we provide. Our reporting processes are improving all the time and we are recording more information about each incident,” Mr Meates says.

“Falls causing harm occur in and out of hospital and mainly affect older people. This is an international problem and there isn’t a quick fix or ‘one size fits all solution’ – a range of strategies are required.”

The CDHB’s Clinical Board has set a goal of zero harm from falls and at the moment the CDHB is working to understand the factors that make falls more likely in order to progressively limit the risk.

“Harm through falls isn’t a new thing, however as our population ages it is a growing problem, and it’s one we intend to erase completely,” Mr Meates says.

“I am incredibly proud of the people who work across the Canterbury Health System. Reducing harm from preventable errors is ongoing work. The responsibility is shared by us all to do everything we can to continuously improve the processes and systems that underpin our actions. We will certainly continue working towards zero harm from falls during 2012.”


Background information and frequently-asked questions

What is an adverse event?

An adverse event is a health care event causing patient harm that is not related to the natural course of a patient’s illness or underlying condition.

A serious adverse event requires significant additional treatment but is not life-threatening and has not resulted in major loss of function.

A sentinel adverse event is life-threatening, or has led to an unanticipated 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 forty nine serious and sentinel adverse events, the majority (38) were falls, with the remaining 11 falling in the category 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?

Work is underway in the community, where any health professional seeing an older person in their own home is asked to help identify and rectify any identifiable ‘trip’ factors that could cause a person to fall. Other in-home programmes work with individuals to increase their strength and balance through exercises.

In the hospital setting a number of initiatives are underway, including:

• All patients are assessed on admission to determine whether they are at risk of a fall.

• A study is underway at The Princess Margaret Hospital where any patient who experiences a fall in the medical wards is interviewed by one of three nurses who are collecting detailed information to help identify risk-factors.

• ‘Sticky socks’ i.e. special socks with non-slip soles are worn by patients known to be at higher risk of a fall. The socks help them avoid slipping by providing a better grip on the floor surface.

• Increased staff education – an e-learning package provides advice for clinical staff.

• Planning is underway to introduce an electronic incident management system to enable closer monitoring of trends and identify any ‘hot spots’.

• Changes to work practices being introduced include toileting strategies and more frequent ‘rounds’ or checks on patients as many falls occur when older people are going to the toilet. Managing delirious patients is another area where more staff training is also occurring.

• Sensor systems which detect movement are also being investigated

• Raising awareness of falls occurs via a highly visible ‘Safety Cross’ poster where the number of falls is recorded and during April, an awareness campaign is taking place.

The report Making our Hospitals Safer can be viewed at

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