Learning from Adverse Events
Reporting serious adverse events nationally is an important
part of improving health outcomes for New Zealanders by improving
safety, and encouraging open and transparent reporting of incidents
when something goes wrong.
An adverse event is an incident which results in harm to people
using health and disability services. Where those adverse events
are serious these are reported to the Health Quality & Safety
Commission, in line with its national reportable events policy.
Serious adverse events are in general those events where serious
harm to a consumer or death has occurred.
The Learning from Adverse Event report is used to support
our continuous quality improvement strategy, focusing on shared
learning to improve systems and minimise the possibility of
You can review our latest report below and/or see the Health Quality &
Safety Commission website for the national
Actions Being Taken In Response
to Falls Events
The BOPDHB has an established falls prevention programme which
is continually monitored and reviewed to ensure best practice is
applied to reduce harm from falls.
Currently there are two falls working groups in operation. One
reviews the organisational Reportable Event Forms (REFs) related to
a fall and the second monitors what is happening nationally,
regionally and locally.
Some examples of outcomes from these groups
- changes to floor mopping processes and associated
- ongoing education emphasises the need for reassessment of falls
risk care plan when patient mental status changes
- ward unit level work has adopted a bottom up approach giving
individual wards ownership of the programme
- intentional rounding includes environmental check, including
that aids are within reach
- non-slip socks standardised to socks with grips all around the
foot and better fitting.
The falls prevention programme has an emphasis on documented
falls risk assessment and care plan. Compliance with falls risk
assessment and care plan monitored through the quality and safety
Improving documentation will remain a focus area in this coming
BOPDHB Quality Accounts
November 10, 2016