Serious adverse events must be reported to the Health Quality and Safety Commission (HQSC) so that lessons can be shared about how to prevent similar events in the future. Adverse events are rated according to the severity of consequences to the patient. Events are given a numerical rating called a severity assessment code (SAC) rating[1]. SAC 1 and 2 events are the most serious adverse events and the events that must be reported nationally to the Health Quality and Safety Commission.
Serious adverse event reports also inform the Commission’s and DHBs’ quality and safety programmes. The Health Quality and Safety Commission produces a national report on serious adverse events each year, based on information provided by DHBs. Each DHB produces a report providing further detail on its serious adverse events for that reporting year. The FY 2016/2017 serious and sentinel event report was the ninth year of reporting.
|
Financial Year |
Total # of serious adverse events |
Events related to falls resulting in major harm |
|
2006/2007 |
22 |
|
|
2007/2008 |
11 |
|
|
2008/2009 |
20 |
2 |
|
2009/2010 |
17 |
9 |
|
2010/2011 |
29 |
19 |
|
2011/2012 |
29 |
13 |
|
Improvements made to our reporting systems |
||
|
2012/2013 |
50 |
37 |
|
2013/2014 |
51 |
39 |
|
2014/2015 |
48 |
37 |
|
2015/2016 |
42 |
34 |
|
2016/2017 |
45 |
35 |
Waitemata DHB Adverse Events Report for 2016/2017
Waitemata DHB’s adverse event report for the financial year 2016/2017 has been published on our organisational website.
What is an Adverse Event?
An adverse event is an incident which results in harm to patients[2].
As part of Waitemata DHB’s commitment to providing safe care for patients, we have a process in place for investigating adverse events that occur in our services. The purpose of investigating adverse events is to determine the underlying causes of the event so that improvements can be made to the systems of care to reduce the likelihood of such events occurring again.
References
- Severity Assessment Criteria (SAC) tables are provided by the Health Quality and Safety Commission (HQSC)
- The term adverse event is defined in the National Reportable Events policy