Fall in reported number of hospital harm cases

Ma¯ori are less likely to have adverse events reported within the healthcare system, according to a report released yesterday by the Health Quality and Safety Commission.

There were a total of 916 adverse events reported to the commission in the 12 months to

June this year. District health boards (DHBs) accounted for 566 of those, down from 631 reported by the commission for 2017-18.

Delayed diagnoses, infections, falls and not recognising a worsening patient all contribute to adverse events, where a patient is seriously harmed through unintended or unexpected events.

Taranaki DHB reported 11 adverse events during the period.

The commission’s clinical lead on the adverse events programme, Dr David Hughes, said Ma¯ori were affected by these types of events when there was more scope for implicit bias to impact on their care.

‘‘We are currently undertaking research into wha¯ nau Ma¯ ori experiences of adverse events,’’ he said.

Patients falling over was one of the most common problems across the country, accounting for 255 of DHBs’ reports. But it was clinical mismanagement that made up the majority of mistakes, with patients missing out on referrals and being diagnosed late. Included under clinical management were 10 cases where medical equipment left was inside patients.

The vast majority of mistakes took place in the public sector, with 100 adverse events reported by members of the NZ Private Surgical Hospitals Association.

Total reported events had fallen for the first time since

2011-12.

The report emphasised that the standard of healthcare in New Zealand was generally high – a typical year sees more than

1 million hospitalisations in public healthcare and only a small number of them end up with a patient suffering a harmful event.