Changes follow hospital deaths

File photo.

A total of 21 “serious adverse events” have been reported by the Rotorua based Lakes District Health Board (DHB) over the 2017/18 period.

The DHB has reported 11 deaths through inefficiencies.

The deaths were registered in the areas of clinical process and mental health.

Dr Sharon Kletchko, Quality Risk and Clinical Governance director, says the DHB “very much” regretted harm to patients and whānau “as the result of our services”.

“Reporting serious adverse events means we not only open up to our community about these events but the process enables us to go the next step, which is making sure it does not happen again,” Kletchko says.

“This is done through our engagement with our health professional staff and the adoption of improvements to the care we provide.”

The DHB has reported the following, in a recent statement:

Twelve general events (down one from 13 last year) and 2 ARR events (new category) – over 12 months:
10 related to clinical process (assessment, diagnosis, treatment and general care), included the 2 ARR events. Four of these events resulted in death.
 3 hospital acquired infections.
1 fall.
13 events occurred in Rotorua, 1 in Taupo.

Seven mental health matters, all resulting in death (over a period of 18 months)
4 in Rotorua.
2 Taupo.
1 across both sites.

A range of improvements has been made, as follows:

■ The new falls assessment and care plan document that was in development last year has now been implemented. A network of falls link nurses in the wards has been set up and training provided with regular study days for these link nurses.
■ A change in protocol has occurred in Radiology for the detection of a particular diagnosis to align with international best practice.
■ New paediatric analgesia guideline has been developed and included in the medication safety training package for new house officers.
■ A Paediatric Early Warning Score education package has been developed and placed on the orientation programme for new house officers.
■ A change in the Radiology information system has occurred and the order of display of old and current films is now always consistent.
■ A print out of the most recent smear report logged with National Cervical Screening Programme is routinely made available on all women who attend the gynaecology clinic. This is now standard practice.
■ An information pack has now been developed for family/whānau of patients who die suddenly in hospital.
■ As a result of some of the mental health events, reviews of triage and multidisciplinary team processes are currently underway.
■ As of February 2018, a dedicated Crisis Assessment and Treatment Team based in Taupo for the Taupo-Turangi region was installed.


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