Your DHB

Serious Adverse Events 2013/14


Questions and Answers Relating to National Data

Provided by the Health Quality & Safety Commission.


What are serious adverse events (SAEs)?

An adverse event is an incident which results in harm to people using health and disability services. Serious adverse events (SAEs) are reported by health and disability providers in accordance with the Commission's national reportable events policy, and in general are those incidents which have resulted in a patient dying or suffering serious harm.   

The SAE report published by the Health Quality & Safety Commission (the Commission) does not record all adverse events that occurred in public hospitals and other health care settings. It records only those considered by district health boards (DHBs) and other reporting organisations to meet the criteria to be considered a serious adverse event.


How many SAEs were there?

In 2013/14, DHBs reported a total of 454 SAEs. Non-DHB providers (such as private surgical hospitals, aged care homes, disability services, the National Screening Unit and hospices) reported an additional 104 SAEs.

The number of DHB-reported events rose by four percent from 2012/13, and by 150 percent since the first report on SAEs was published in 2007 (when DHBs reported 182 SAEs for 2006/07).

The 454 SAEs reported by DHBs for 2013/14 include:

  • 248 cases of serious harm from falls, which make up 55 percent of all events reported by DHBs. Of these, 98 cases resulted in a patient suffering a broken hip
  • 158 cases involving clinical management, including delays in treatment, assessment, diagnosis and observation
  • 30 cases involving medication dispensing, prescribing or administration
  • 5 other patient accidents (not falls)
  • 13 other events.

In general, the number of serious adverse events occurring in each DHB is proportionate to the population each DHB serves.

The 104 SAEs reported by non-DHB providers for 2013/14 include:

  • 5 reports from two aged residential care providers, including four cases of serious harm from falls and one of serious adverse behaviour of a relative
  • 1 reported event from a disability service for attempted self-harm
  • 11 reports from two hospices, including five cases of serious harm from falls, three medication events, one clinical management event, one pathological fracture and one case of self-harm
  • 1 reported event from a non-governmental organisation of a resident setting light to a residence
  • 3 reported events relating to the Universal Newborn Hearing Screening and Early Intervention Programme, and two relating to pathology services
  • 2 reported events from a primary health organisation, including one case of serious harm from a fall and one relating to diagnosis/assessment.

The Commission's 2012/13 report included SAEs from ambulance services, but this reporting will now be published by the Ministry of Health. 


Does the report include incidents affecting people using mental health and addiction services?

No. In 2012/13, the Commission released a separate report on serious incidents affecting people who used mental health and addiction services. Most of these cases were of suspected suicide.

To coordinate efforts in this difficult and complex area, the Commission has begun collaborating with the Director of Mental Health to publish serious adverse events involving people using DHB mental health and addiction services. These events will be included in the Director of Mental Health's annual report rather than in a separate report by the Commission.    


What is the Commission doing about patients who suffer broken hips as a result of falls in hospital?

Ninety-eight of the falls reported during 2013-14 resulted in the patient suffering a broken hip (fractured neck of femur).

While there have been improvements in hospitals reporting these cases (see comment by Richard Hamblin in the report, page 16), this needs to translate into a reduction in the number of patients who suffer serious harm from falls. The sector has focused on preventing injury from falls, but this is a challenging area, with much of falls prevention needing to take place in a patient's own home, or in residential facilities in the community.

It is likely to take some years for the effects of vitamin D prescribing, and improving balance and strength to affect the rate of serious injury in falls. The challenge is reflected by DHBs which have good patient safety cultures, yet still have patients who suffer harm from falls.


Why has the number of SAEs increased?

The number of SAEs has progressively increased from 182 in 2006/07 to 454 in 2013/14. The latest figure is a four percent increase in SAEs, up from 437 in 2012/13.

The increase reflects the health sector's growing commitment to reporting SAEs, and to the improved systems they have developed to carry out this reporting.


How accurate is the SAE data? 

Based on cross-checking of data, the Commission believes the number of reported SAEs is an increasingly accurate picture of the actual number of adverse events that take place, particularly in some areas. For example, in 2013/14 the number of broken hips in hospital reported by DHBs is almost identical to the number of broken hips reported in the National Minimum Data Set, which records information produced by public hospitals when a patient is discharged. 



How do New Zealand's levels of SAEs compare with levels in other countries?

It is difficult to gather accurate statistics on each country's level of adverse events, but the increasing amount of SAE data we are recording will give us a better idea of our performance over time. At present, we believe New Zealand's SAE levels are broadly comparable to levels in countries such as Australia and the United Kingdom.  


Is it possible to say exactly how many people died in 2013/14 as a direct result of an SAE?

No. We know that of the 454 SAEs reported, 73 people died. This compares to 82 deaths out of the 437 SAEs reported in 2012/13, and to 91 deaths out of the 360 SAEs reported in 2011/212. However, this was not necessarily a result of the adverse event.   


What are individual DHB results?

Table 1 below sets out events reported annually by DHBs since 2006-07. Comparing one year with another is problematic, however, as DHBs are steadily improving their reporting systems. So, the number of serious adverse events has not necessarily increased, but more events are being reported and reviewed each year.


Table 1

DHB

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

2013-14

Northland

6

5

7

4

4

10

9

15

Waitemata

22

11

20

17

29

29

50

51

Auckland

26

30

31

32

54

62

67

82

Counties Manukau

7

23

29

38

35

24

45

47

Waikato

24

36

60

52

51

26

36

39

Bay of Plenty

1

5

5

13

14

10

12

9

Lakes

1

6

3

7

4

7

17

9

Tairawhiti

1

3

7

3

5

5

4

2

Taranaki

5

7

2

7

3

18

5

6

Whanganui

3

4

7

9

9

4

5

12

Hawke's Bay

12

7

5

9

7

11

11

10

MidCentral

4

2

8

18

22

15

20

19

Hutt Valley

2

7

10

10

4

10

11

8

Wairarapa

1

2

2

4

2

4

4

7

Capital & Coast

14

16

22

18

16

19

21

22

Nelson Marlborough

7

5

6

1

8

6

9

8

West Coast

5

11

2

4

4

4

11

13

Canterbury

22

41

44

69

49

49

47

55

South Canterbury

3

12

7

9

10

17

17

6

Otago

3

7

20

39

 

 

Southland

13

18

11

9

Southern

 

40

30

36

34


Rate of SAEs per 100,000 bed days

The funnel plot below (Figure 1), presents SAEs as a rate per 100,000 bed days. Each numbered dot represents a DHB, with the smallest (Wairarapa) being furthest to the left and the largest (Auckland) being furthest to the right. The national average rate of SAEs for 2013/14 (15 per 100,000 bed days) is represented by the straight horizontal line. The curved lines, or the 'funnel', show the point where a given SAE rate differs from the average by more than can be explained by chance alone. The funnel is so shaped because, as the number of admissions increases, the amount of variation that can be explained by chance decreases.

Differences between DHBs within the funnel can be explained by chance, but any DHB which lies outside the funnel is far enough away from the average that the difference can't be explained by chance alone.

However, a high rate of reporting may be due to a positive culture, where the reporting of adverse events are encouraged. It would therefore be incorrect to conclude that those DHBs higher on the scale, below, are less safe than others - all that can be deduced is that they have reported more adverse events.

 

Rate of SAEs per 100000 bed days graph

DHB

Legend

SAE per 100,000 Bed days

West Coast

1

46.75

Wairarapa

2

30.81

Whanganui

3

30.18

Auckland

4

20.19

Mid Central

5

16.88

Southern

6

16.83

Waitemata

7

16.31

Lakes

8

16.12

Northland

9

15.96

Counties Manukau

10

14.84

Canterbury

11

13.56

Waikato

12

12.99

Nelson Marlborough

13

11.24

South Canterbury

14

10.88

Capital & Coast

15

9.99

Hawke's Bay

16

9.77

Hutt Valley

17

9.71

Taranaki

18

9.22

Tairawhiti

19

7.85

Bay of Plenty

20

6.45


Is SAE reporting voluntary?

DHBs are required to report SAEs to the Commission. Many non-DHB health providers - such as private surgical hospitals, aged residential care facilities, disability services, the National Screening Unit and hospices - are choosing to do the same.

Members of the New Zealand Private Surgical Hospitals Association began routinely reporting data on adverse events to the Commission in 2013/14. The association's 25 members are responsible for 35 hospitals and treat about 156,000 patients each year, carrying out half of all elective surgery in New Zealand. The association requires its members to report clinical indicators, including SAEs.


How safe is our health care system?

The standard of health care in New Zealand is generally high, and most people are treated safely and without incident. However, a small number of people are harmed while they receive care.

Every serious adverse event represents someone who has suffered life-changing harm or has died in the care of the health system. Patients harmed by health care can expect their case to be reviewed to find out what happened and what can be done to prevent the same thing from happening to someone else in the future.

It should be noted that international literature does not support using the number or rate of reported events as a way to judge a hospital's safety, as there is considerable variation in the reporting and event rates.

For example, DHBs reporting the most events may have better reporting systems or a stronger safety culture, with a lower threshold for performing a detailed review. Larger DHBs are likely to report more events than smaller DHBs, which may reflect the size of the populations they serve as well as the mix of health services they provide.


Is there an acceptable, or expected, number of adverse events?

International studies show 10 to 15 percent of hospital admissions can be associated with an adverse event, although about half of these occurred before admission to hospital, in other health settings. In addition, many adverse events are known complications of treatment and are not preventable.

However, many events are preventable. The Commission is paying particular attention to reducing both the number of adverse events which occur and the harm to patients from these events.


Shouldn't health professionals be held accountable when things go wrong?

They are. There are separate processes to hold clinical professionals accountable for the quality of their work and for maintaining professional standards.

The reporting of incidents aims to continually examine ways to improve health care systems to minimise the risk to patients in the future. Reporting SAEs is about learning from mistakes rather than apportioning blame. 


Is any action being taken to improve the quality of reviews of SAEs?

When patients are accidently injured by the health and disability system, patients and their families want to know what happened, how it happened, and how it can be prevented from happening again.

SAEs are uncommon, so health care professionals may have little experience in answering these questions and may not have access to experts who can help.

To address this issue, the Commission is facilitating a sector capability support programme offering adverse event review training to experienced clinicians in DHBs. To be offered annually, this training is expected to improve the quality of reviews and strengthen the network of experienced reviewers able to offer advice when an incident occurs.


Is any action being taken to prevent SAEs?

The Commission has a very strong focus on preventing SAEs and works closely with DHBs and other health and disability service providers to improve patient safety across a range of areas, including infection prevention and control, medication safety, surgery, falls, mortality review, consumer engagement, and health measurement and evaluation.

In the first week of November, the Commission is co-ordinating the inaugural Patient Safety Week which includes hosting workshops by Dr Jim Bagian, former astronaut and world renowned patient safety expert. Four workshops are being held and will be attended by clinicians, managers and staff from the public and private health sector.

In addition, the Commission is leading a national patient safety campaign, Open for better care, which was launched in May 2013 and is being implemented by DHBs and private health care providers around New Zealand (and in partnership with First, Do No Harm in the Northern region). The campaign focuses on reducing harm from falls, infections, surgery and medication.

The Commission is also responsible for statutory mortality review committees that have a significant role to play in preventing harm.

In the coming year, the Commission will place greater emphasis on responding to reports of SAEs and looking at changes that can prevent them from happening again. We will continue to share the lessons learned from SAE reviews with the health and disability sector.

Further information about the Commission's programme areas is available on the Health Quality & Safety Commission website.

 

Last updated: August 29, 2018