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Waikato focussed on quality and safetyWaikato District Health Board’s 94 sentinel and serious events suggest an organisation with a heightened focus on quality and safety, chief executive Craig Climo said today. Waikato DHB reported 19 sentinel and 75 serious events between July 1, 2003 and June 30, 2007. In the same period Waikato DHB’s health and hospital services’ provider arm Health Waikato discharged from its hospitals 329,646 patients; 85 per cent of them from Waikato Hospital in Hamilton. The events included:
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“Waikato DHB has long encouraged open reporting of events that allows us to consider all factors that could have influenced the situation and that give us the opportunity to identify and address,” said Mr Climo, who joined Waikato DHB as chief executive in August last year. “I’ve been very impressed with the approach at Waikato DHB. The team here believe in open reporting and learning from incidents and I absolutely support that.” Chief medical advisor Dr Tom Watson said many of the patients involved in the adverse events were aware or had been informed that an event had occurred. “While we know many of the patients will be aware of what happened, we cannot guarantee that in every case though.” An 0800 line (0800 100 178) has been set up so any person who wishes to further discuss their actual or possible involvement can do so, said Dr Watson. Those ringing through are asked to leave their name, daytime contact number, the dates they were in hospital, their National Health Index (NHI) number (if known), their doctor’s name and any other details which may be useful. They will be contacted within two working days. Dr Watson said he was convinced DHBs with larger numbers of events reported, and greater details about the events, reflected better local systems for reporting and investigating and probably a superior safety culture. “That’s certainly the case at Waikato. “We have significantly improved the levels of incident reporting over the past 10 years. However there is still room for improvement,” he said. Mr Climo said Waikato DHB was six months into a structured programme to improve its reporting processes further, educating staff and improving the technology associated with the process. “Such is our commitment to quality and safety; we have also volunteered to lead a Quality Improvement Committee national project to improve incident reporting and incident review nationwide. “Where we need to improve our game somewhat is in ensuring that recommendations arising from incidents are monitored to completion,” he said. Dr Watson said initiatives were already in place to do this. Among them included better board oversight and greater clinical involvement in the processes. “Humans do make mistakes, no-one is infallible and whilst we accept the devastating outcomes on patients and their families; the health professionals involved are hugely affected too. For some it can lead to leaving a previously successful career due to the impact of such an incident. “Health Waikato is a large provider of secondary and tertiary services and as such operates in a complex clinical environment. Patients are often already too sick to help by the time we see them and in some cases almost beyond our ability to help them,” said Dr Watson. “For this reason it’s sometimes difficult to identify the extent to which our actions or inactions contributed to the 28 deaths. “The range of diagnostic tests and health-care treatments is constantly expanding and hospital staff do an outstanding job in providing first-rate care to patients. Every month we receive hundreds of compliments about the care we provide to patients and we must not lose sight of that.” Dr Watson said he would be devastated if publicity around the release of the sentinel and serious events stopped any clinical staff from reporting incidents because their mistakes were made public. “We rely on that honesty. Using the data inappropriately may adversely affect the culture of safety and openness that we have steadily built up in Waikato. “Waikato DHB staff and managers have been very supportive of the serious event review process, and in addition often request review of events which do not meet the definitions of serious and sentinel events. There is a strong commitment to learning from adverse events,” he said. Last week David Galler, the principal medical adviser to the Minister of Health, was glowing in his praise of Waikato DHB saying on National Radio that the organisation had a “magnificent reporting system that goes all the way through to what the event was, the classification of the event, a description of it, what steps were taken to intervene, the follow up result and what was learned from the event.” He said Waikato’s system was a “magnificent template” and the organisation had a “healthy reporting culture”.
Mary Anne Gill |