Open reporting key to improving our health system

Open reporting key to improving our health system

Canterbury District Health Board (CDHB) remains committed to transparent and open reporting of Serious Adverse Events, a Health Quality and Safety Commission report shows.

In Canterbury, 58 serious adverse events were reported in the July 2014-2015 year – up slightly on the previous year when there were 56 events.

David Meates, Canterbury DHB chief executive, says all incidents, including near-misses, brought to the DHB’s attention are investigated.

“In all cases measures are put in place to reduce the chance of these events from recurring. Ensuring we remain transparent and have an open reporting culture is key to us being able to make the necessary changes to ensure the same thing doesn’t happen again,” he says.

Mr Meates says preventing adverse events relies on our clinicians’ continued efforts to review and learn from mistakes when they happen.

“We must continually scrutinise and ask ourselves how can we improve these systems and what could we be doing better? Have we missed anything here?

“Because when we stop asking these questions, we stop really caring about what we’re doing and that’s when the chance of things going wrong only increases.”

Canterbury has a strong culture where staff are encouraged to feel safe reporting incidents.

“If they don’t feel safe speaking up, then it’s impossible for us to improve what we’re doing, or learn from what went wrong,” he says.

“Most importantly, we have an obligation to our patients, their family and whanau to be open and transparent and be honest about the care we’ve provided – even if it hasn’t gone to plan.”

Mr Meates says when harm does occur, it’s never easy for anyone involved.

“Nobody in health sets out to deliberately cause harm. If a patient’s condition deteriorates unexpectedly and suddenly, it can have a devastating effect – our staff come to work every day with the aim of improving people’s health,” he says.

“It’s absolutely heart-breaking for everyone involved when the opposite happens.”

The increase in the number of events reported this year reflects Canterbury’s emphasis on learning from system failings, Mr Meates says.

Falls in hospital remain the majority of incidents, counting for 40 out of the 58 events reported this year.

Mr Meates says Canterbury has a ‘whole of system’ approach to falls prevention, in the wider community, rest homes and in hospital.

“We continue to focus on patient assessment and tailoring falls prevention strategies to meet the needs of patients while they are in hospital and when they go home.”

Read the full Canterbury DHB SAE report here.

ENDS

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