Your DHB

Learning from Adverse Events

Reporting serious adverse events nationally is an important part of improving health outcomes for New Zealanders by improving safety, and encouraging open and transparent reporting of incidents when something goes wrong.

An adverse event is an incident which results in harm to people using health and disability services. Where those adverse events are serious these are reported to the Health Quality & Safety Commission, in line with its national reportable events policy. Serious adverse events are in general those events where serious harm to a consumer or death has occurred.

The Learning from Adverse Event report is used to support our continuous quality improvement strategy, focusing on shared learning to improve systems and minimise the possibility of future incidents.

You can review our latest report below and/or see the Health Quality & Safety Commission website for the national report. 

Latest reports:


Actions Being Taken In Response to Falls Events

The BOPDHB has an established falls prevention programme which is continually monitored and reviewed to ensure best practice is applied to reduce harm from falls.

Currently there are two falls working groups in operation. One reviews the organisational Reportable Event Forms (REFs) related to a fall and the second monitors what is happening nationally, regionally and locally.

Some examples of outcomes from these groups are:

  • changes to floor mopping processes and associated education
  • ongoing education emphasises the need for reassessment of falls risk care plan when patient mental status changes
  • ward unit level work has adopted a bottom up approach giving individual wards ownership of the programme
  • intentional rounding includes environmental check, including that aids are within reach
  • non-slip socks standardised to socks with grips all around the foot and better fitting.

The falls prevention programme has an emphasis on documented falls risk assessment and care plan. Compliance with falls risk assessment and care plan monitored through the quality and safety markers (QSM).

Improving documentation will remain a focus area in this coming year.


BOPDHB Quality Accounts


Last updated: January 27, 2021