Adverse events for 2014/2015


What is an adverse event?

An adverse event is an incident which results in harm to patients[1].

As part of Waitemata DHB’s commitment to providing safe care for patients, we have a process in place for investigating adverse events that occur in our hospitals. The purpose of investigating adverse events is to determine the underlying causes of the event so that improvements can be made to the systems of care to reduce the likelihood of such events occurring again.


Serious adverse events reporting

Serious adverse events must be reported to the Health Quality and Safety Commission (HQSC) so that lessons can be shared about how to prevent similar events in the future. Adverse events are rated according to the severity of consequences to the patient and the likelihood of the event happening again. Events are given a numerical rating called a severity assessment code (SAC) rating[2]. SAC 1 and 2 events are the most serious adverse events and the events that must be reported nationally to the Health Quality and Safety Commission.

Serious adverse event reports also inform the Commission’s and DHBs’ quality and safety programmes. The Health Quality and Safety Commission produces a national report on serious adverse events each year, based on information provided by DHBs [view national reports on HQSC website]. Each DHB produces a report providing further detail on its serious adverse events for that reporting year. The FY 2014/2015 serious and sentinel event report was the seventh year of reporting:

Financial Year

Total # of serious adverse events

Events related to falls resulting in major harm

2006/2007

22

 

2007/2008

11

 

2008/2009

20

2

2009/2010

17

9

2010/2011

29

19

2011/2012

29

13

Improvements made to our reporting systems

2012/2013

50

37

2013/2014

51

39

2014/2015

48

37


Waitemata DHB adverse events report for 2014/2015

Waitemata DHB’s adverse event report for the financial year 2014/2015 has been published on our organisational website - view our serious adverse events report for FY 2014/2015.


  1. The term adverse event is defined in the National Reportable Events policy
  2. Severity Assessment Criteria (SAC) tables are provided by the Health Quality and Safety Commission (HQSC)

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