A serious adverse event is one which has led to significant additional treatment, is life threatening or has led to an unexpected death or major loss of function. District health board (DHB) providers are required to review these events and report them to the Health Quality and Safety Commission.
Over the past year 454 serious adverse events were reported; more than one a day. 248 (55 percent) of these events were falls that resulted in serious harm – fractures, serious wounds and serious head injuries.
We’re concerned about this for many reasons.
Each one of these ‘events’ happened to a person, a family, a community. Each event will have caused considerable pain and suffering, loss of mobility, confidence, independence and increased length of stay in hospital, along with the increased costs that go with all those outcomes.
Every member of the nursing team caught up in a serious event will also have found the experience very distressing. Nobody ever goes to work expecting that a serious event is going to occur on their shift, and nurses only ever want the best outcome for their patients.
NZNO is also concerned about the overall increase of events since the last report – especially in those events that are considered nurse sensitive outcome indicators – pressure areas, infections and falls.
The number of falls reported has gone from 56 in the 2008 report to 248 in 2014; a staggering increase that cannot be attributed to improved reporting alone. The fact of the matter is that for all of those falls which caused serious harm, there will be numerous others that don’t meet the severity threshold, so do not appear in the report. There will be even more that are not reported at all.
So what might be contributing to this alarming trend?
We are aware of changes to DHB policies in regard to specials and watches – these are expensive and need special approval. Are they not being approved when they should be?
We know that older adults are coming to us more unwell and with complex needs. Is it increased acuity that is contributing to the increase in serious adverse events?
Nurses are telling us that they are stressed at work – finding it challenging to meet patients’ needs. Sometimes bells don’t get answered in time… serious accidents can result. Are staffing numbers and skill mix not adequate to meet patient demand?
And if that’s the case, we have to ask, why not?
We believe that health services must be funded appropriately, so every patient receives the care they need, when they need it. And so every member of the healthcare team can go to work knowing all the supports and resources are in place to provide excellent care to every patient.
More needs to be done to investigate why and how serious adverse events occur and steps put in place so they no longer happen. If that means extra funding and a different number and skill mix of staff, so be it.