Almost 100 people suffered a broken hip while being cared for by public hospitals in the past year and a report out today says that rate of harm is far too high.
The latest report by the Health Quality and Safety Commission on serious adverse events says district health boards reported 248 cases where patients suffered serious harm from falls.
Twenty-nine cases involved fractures from the foot to the thigh. Photo: CORBIS
Ninety-eight cases involved a broken hip, 22 a serious head injury, 43 instances of fracture from the hand to the shoulder, 14 cases of fractured pelvis, and 29 fractures from the foot to the thigh.
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The commission says falls accounted for 55 percent of all cases of harm reported by DHBs.
Commission chair Alan Merry said the rate of harm from falls equated to two patients a week.
"This is very disappointing given the considerable effort going into reducing harm from falls, and shows this must continue to be an area of high priority for the commission and the sector."
The report says that on admission to hospital, patients should be assessed for their relative risk of falling.
Overall, there was a total of 454 serious adverse events over the year to June, a 4 percent rise on the year before, which the commission puts down to improved reporting.
The report says that of events reported, 73 people died. This compared to 82 deaths last year and 91 in 2011-12. The deaths were not necessarily a result of the adverse event.
Non-DHB providers who have joined the reporting system voluntarily reported a total of 104 events. These providers included private surgical hospitals, some rest homes, disability services, the National Screening Unit and hospices.
Clinical management problems were the second most frequented reported events.
The 158 reported cases included delays in treatment, assessment, diagnosis and observation. The report says most cases were reported not because of a preventable error or omission resulting in patient harm, but because the outcome for the patient was serious and unexpected.
It included 31 events, for example, such as a baby being stillborn, or a patient unexpectedly dying after an operation.
There were 28 events reported due to a significant delay in a patient's care caused by failings in hospital systems. The commission says these cases tend to fall into four main categories, including x-ray reports that identify an abnormality and recommend further treatment or investigation which does not occur. The report says one DHB has now changed its procedures so all radiology results are now signed off.
There were 14 cases reported of patients undergoing an incorrect process, including five patients who had an unnecessary procedure, three who had a procedure at the wrong site, and four patients who had a procedure intended for someone else. The commission report says this is very rare. Where it happened is not detailed in the main report, although individual DHBs will release their own reports later today.
There were 11 reported events of items left inside a patient following surgery. Six of these occurred in operating theatres and involved clips, a needle, a swab, a stapler and anvil, and laparoscopic equipment. Five of these events occurred in obstetric care, and involved swabs left inside women who had given birth.
The report says during the past year in response to this one DHB changed its obstetric processes and the use of swabs is now covered by the same tight counting processes used in operating theatres, and tags that can be seen on x-rays are also used.
Thirty cases of serious adverse events involved medication prescribing, dispensing or administration.
The commission says that over the next year it will be working with the health sector to increase expertise in learning from adverse events, including providing training in the review of events.