Your DHB

Adverse Events 2017/18

When a person has an adverse outcome as a result of their care with the BOPDHB we resolve to report the event, thoroughly review it and implement any resulting recommendations, to ensure no other person and their family/whanau has the same experience.

In 2017/2018, 631 people nationally had an adverse outcome which met the criteria for reporting to the Health Quality and Safety Commission (HQSC).This is an increase on previous years and is likely due to changes in requirements for reporting along with better reporting within DHBs.

However, even with increased reporting the serious adverse events numbers at the BOPDHB for 2017/18 have come down from 2016/17.

Learning from Adverse Events | 1 July 2017 to 30 June 2018 | What are the individual DHB figures? This table shows events reported annually by DHBs since 2015-2016. DHBs are steadily improving their reporting systems and more events are being reported and reviewed each year. It is not valid to compare the figures of different DHBs for a number of reasons, including widely varying population bases. 

DHB adverse event numbers were correct at the time of data analysis for this report. There may be some variation in numbers included in this report compared with DHB data. This may relate to timing of reporting or reclassification following review.  

DHB

2015-16

2016-17

2017-18

Northland

17

21

19

Waitemata

42

45

122

Auckland

80

95

92

Counties Manukau

58

48

42

Waikato

41

44

49

Bay of Plenty

9

14

13

Lakes

11

13

14

Tairāwhiti

8

6

5

Taranaki

7

9

9

Whanganui

17

9

1

Hawke's Bay

13

21

24

MidCentral

17

21

20

Hutt Valley

7

6

15

Wairarapa

3

8

7

Capital & Coast

24

18

27

Nelson Marlborough

41

9

 7

West Coast

8

9

8

Canterbury

43

73

83

South Canterbury

12

20

8

Otago

 

 

 

Southland

 

 

 

Southern

62

53

66


This year also represents the first time since 2013 that mental health and addiction service events have been included in the Adverse Events reporting. 

Adverse events

Event Type

Number

 

16/17

17/18

Clinical Management

4

5

Healthcare Associated Infection

4

0

Medication/IV Fluid

0

0

Medical devices or equipment

0

0

Consumer accidents

0

0

Falls

7

8

TOTAL

15

13

Always report and review events

Event Type

Total

SAC 2

SAC 3

Sac 4/

near miss

Wrong blood component

0

0

0

0

Retained foreign object post - procedure

3

0

1

2

Wrong site, wrong implant/prosthesis, wrong consumer/procedure

4

0

2

2

Mental Health Adverse Events 

Type of event

Community

Inpatient

Total

Suspected Suicide

13

1

14

Serious Self Harm

0

1

1

Serious Adverse Behaviour

0

0

0

TOTAL

13

2

15

Last updated: March 8, 2019