Serious Adverse Events Report 2013-14

30 October 2014
Following the release of the Health Quality & Safety Commission’s (HQSC) Serious Adverse Events report, Whanganui District Health Board (WDHB) is satisfied it has the policies and processes in place to support safe care in Wanganui Hospital and that when an incident which causes serious harm or unexpected death does occur, it is thoroughly investigated and learnt from with any identified improvements to care being made.  
The report released today shows Wanganui Hospital had 12 incidents that required reporting to HQSC resulted in the 2013-2014 year – nine falls that resulted in broken bones and three unexpected deaths.
WDHB director of nursing Sandy Blake says the organisation strives to always being open and honest with patients and their families and shares all findings of any investigations.
“Any deaths which occur in Wanganui Hospital, whether expected or not, are reviewed as we know we can always learn from the review and the families,” says Mrs Blake.
“We consider it very important that we are open and transparent with patients and their families about the adverse event and the steps taken to reduce further such events. In all cases the families are provided with a copy of the final investigation report and offered the opportunity to discuss its findings with staff.”
Mrs Blake says the reporting system the WDHB has in place is robust and that the information passed onto the HQSC is an honest reflection of the serious incidents which have occurred at Wanganui Hospital.
“We actively promote a culture in which staff are encouraged to report all events whether harm occurs or not,” says Mrs Blake.
“Policies and processes are in place to support the reporting and investigation of every incident of harm,” Mrs Blake says. “Findings of investigations are shared with the patient and/or family as well as the clinicians involved in the care so that any recommendations to prevent that harm from happening again are actioned.”
The DHB developed a process of checking by audit that the recommendations from the reviews have been implemented and are working. This process in conducted out of respect for those that have been sadly harmed or died in our care.
Summaries of the incidents which caused harm to Wanganui Hospital patients can be found here.
The HQSC’s Serious Adverse Events report is available at