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Six people harmed while in DHB care

Wairarapa Hospital in Masterton. PHOTO/FILE

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Wairarapa District Health Board reported six adverse events to the Health Quality and Safety Commission this year.

Of the six events reported, three related to falls resulting in fractures, while the other three related to clinical management events, such as assessment, diagnosis, treatment and general care.

The number was consistent with the average number of reported events over the previous five years.

Unlike in previous years, the DHB did not make public further details about the incidents, stating on its website, “Given the small number of events and the small size of the DHB, no further detail will be provided in the interests of protecting the identity of the patients and whanau involved”.

In a statement, chief executive officer Dale Oliff apologised on behalf of the DHB to affected patients.

“I offer our sincere apologies to the patients and their whanau impacted by these adverse events,” she said.

“We are extremely grateful for the opportunity in front of us to now improve our care from their experience.

“We have thoroughly reviewed each event, identified contributing factors and learnings, and we are committed to implementing the recommendations that have been made.

“We readily share the learnings with our staff and teams to ensure we continue to always improve, and provide the best patient care we can deliver for all of our patients at all times.”

The family of a Wairarapa woman involved in a serious medication adverse event at Capital and Coast DHB feared a repeat of their experience.

They said they were “underwhelmed” by the DHB’s report.

“It was late, according to the DHB’s own timeframes, and filled with errors,” the family said.

“And it did not cover the full range of our experience at the hospital.”

The review was not considered complete until the patient responded, they said.

“We have only recently received the report. Given our family situation, we haven’t really had time to take it in.

“But we will be putting across our disappointment about it, and that we are not confident that a similar situation, or worse, could happen to another whanau.”

According to the Wairarapa DHB website, reporting adverse events was part of a broader safety framework within New Zealand to make healthcare safer.

Each event represented someone who had suffered harm or died in the care of the health system.

“The purpose of adverse events reporting is to understand the experience of the affected consumers, families and whanau to improve consumer safety, encourage open communication and learn from the events.

Adverse event reviews seek to understand what happened, why it happened, and what needs to be done to make the system safer,” it stated.

“DHBs are steadily improving reporting systems, and more events are being reported and reviewed each year. There has been an increase in overall reporting of adverse events to the commission. This demonstrates an open culture of reporting and a willingness to focus on systems learnings, to reduce preventable harm.”

When asked whether a full report of adverse events would be published as in previous years, a DHB spokesperson told the Times-Age “individual DHB reports are not required ”.

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