10 Nov 2016

Clinical errors cause most patient harm in hospitals

4:16 pm on 10 November 2016

Clinical management problems have overtaken falls as the most frequently reported cause of patient harm in public hospitals.

 Doctor with a stethoscope writing on a clipboard.

Clinical management errors have overtaken falls as the most frequently reported problem in public hospitals. Photo: RNZ / Diego Opatowski

In its latest annual adverse events report, released today, the Health Quality and Safety Commission says that includes problems after delays in follow-up eye appointments.

The impending release of today's report prompted the Southern District Health Board (DHB) to last week reveal it had written to 4618 patients waiting for follow-up eye appointments, telling them they faced longer waits.

That was followed by confirmation by the Nelson Marlborough DHB that it had 800 patients waiting for follow-up appointments - up to half of them for excessive times.

In its report, the commission said DHBs reported a total of 520 adverse events, or potentially preventable errors in public hospitals, and 154 by other providers such as private hospitals.

For the first time, clinical management overtook falls as the most frequently reported problem in public hospitals. That included 44 incidents related to eye treatment, and the commission said in some cases eye conditions deteriorated.

Clinical management included clinical administration, processes or procedures, and resources and management.

The report found there were 245 of these types of problems over the year, 47 percent of the total and the most common type of problem reported by DHBs.

The 44 eye-treatment incidents in this category made up 18 percent of all clinical management problems and included a large number of ophthalmology or eye patients, mostly follow-up appointments.

The commission commended Southern and Nelson Marlborough DHBs for "showing leadership" in their reporting on the topic.

"These DHBs are currently reviewing these events and will make improvements based on the findings," said commission chair Alan Merry.

A total of 237 falls were reported by DHBs during the year from July 2015 to June 30 this year, making up 46 percent of total errors reported. Thirty-five percent of the falls - 84 - resulted in a fractured neck of femur. Serious falls in public hospitals reduced by 14 percent.

The report said when the commission was launched in 2010, falls in public hospitals accounted for a substantial percentage of reported adverse events, and reports of harm from falls were increasing.

Medication-related events were the third most reported, with 21 incidents over the year.

Ambulance services, which also contributed to the reporting, said there were more than 480,000 calls made to 111 for their services during the year - 6 percent more than the previous year.

They reported 101 potentially harmful mistakes.

"This increase reflects an ambulance service that has significantly improved and deepened its culture and systems to confidently identify and report adverse events. It is critical for ambulance services to learn from and reduce these risks."

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