Failings revealed in adverse event reporting

green-party

Tue Jul 03 2007 12:00:00 GMT+1200 (New Zealand Standard Time)

Failings revealed in adverse event reporting

Tuesday, 3 July 2007, 10:26 am
Press Release: Green Party

2 July 2007

A Green Party survey of the country's District Health Boards highlights the shambolic state of current adverse event reporting, and the urgent need for a comprehensive mandatory reporting system across the sector.

The survey analysed the responses of 20 District Health Boards to questions from the Health Select Committee for the 2005/06 financial year and found the current system of reporting to be fragmented, sloppy and potentially dangerous. Not one DHB was able to provide an estimate of how much adverse events were costing, although the Centre for Adverse Reactions Monitoring estimates that 30% of public hospital expenditure is spent dealing with adverse events.

"We know that thousands of New Zealanders suffer from an adverse event while in hospital, and that adverse events are costing the taxpayer an estimated $870 million a year. But the present system of reporting is so inadequate, it's impossible to work out how serious the situation is in New Zealand, or whether it's getting worse or better," Green Party Health Spokesperson Sue Kedgley says.

"There are huge gaps in reporting," Ms Kedgley says. "There aren't even standard definitions of what constitutes an adverse event, or a more serious 'sentinel' event. This makes it impossible to compare the performance of DHBs, or to measure trends over time. It also makes it impossible to calculate the total number of adverse events in hospitals, to get a true picture of patterns or to provide rapid intervention in the event of an emerging pattern.

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"This is an extremely serious gap, especially when we consider that each adverse event costs on average $10,200. Medication-related events alone add an average of almost eight days to a hospital stay, and 12 percent are associated with permanent disability or death."

"Canterbury DHB reported 10,339 adverse events last year, and Capital Coast Health 3227, but MidCentral DHB stated that they were unable to provide any figures. In the absence of any national monitoring system, we don't know whether these differences are due to the lack of standardised reporting, or other factors.

"If we are to reduce the number of adverse events in New Zealand, we urgently need a coordinated, nationwide system of adverse reactions reporting and a requirement that all DHBs report on adverse reactions in their accountability documents, in the same way as they do with waiting lists," Ms Kedgley says.

"There are significant gains that could be made from sharing information and standardizing prevention methods, but this is impossible while there is no coordination, no standard reporting or accountability requirements. This lack of coordination is also resulting in missed learning opportunities for medical professionals, and increased risk for patients," Ms Kedgley says.

DHB Adverse Events Survey Results

This survey presents the responses provided by twenty DHBs to questions asked by the Health Select Committee for the 2005/06 financial year.

* Among the DHBs surveyed, adverse events are routinely reported. In a number of cases, they are on average being reported several times each day.

* However the definitions of 'adverse events' vary, which makes it very difficult to make any comparisons between the DHBs. For example, Taranaki uses the term 'reportable events'.

* The DHBs also vary in their use of the term 'sentinel' events. For example, Waikato categorises medication failures as 'incidents' while Nelson/Marlborough categorises the same incident to be a sentinel event.

* No DHBs were able to provide the Health Select Committee with estimates of how much adverse events were costing, although Centre for Adverse Reactions estimates that 30 percent of public hospital expenditure is spent on adverse events costs.

* CARM also estimates that 43.9 percent of medication-related events are associated with error by a health professional and are therefore preventable. Yet these errors can carry high costs: 12.3 percent of medication-related events results in permanent disability or death.

* All surveyed DHBs reported numerous adverse events as the result of incorrect pharmaceutical use.

* Many DHBs revealed similar results in the categories of adverse events. For instance, Auckland and Waitematä both experienced a similar percentages of 'falls', 'medication and fluid errors' and 'skin and tissue' related adverse events. Similarly, the Bay of Plenty and Hawke's Bay & Chatham Islands DHBs each experienced a heightened number of 'moderate' and 'minor' adverse events, while having far fewer 'major', 'minor' and 'insignificant/minimal' adverse events

* Of the eight DHBs that reported sentinel events, six said 'medication errors' were the cause.

These results present a number of issues relating to reporting systems, information presentation and prevention methods. The Green Party makes the following recommendations:

* There needs to be a uniform definition of terms used to identify adverse events across the sector.

* Adverse events needs to be reported on in annual accountability documents. This will encourage DHBs to become more accountable and proactive in addressing adverse events.

* Addressing adverse events and reactions requires national coordination and monitoring. Similar category results demonstrate that DHBs could benefit from the standardisation of prevention methods.

* An electronic reporting system, which frees up the time of already over-burdened health professionals would increase the likelihood of good reporting and provide opportunities for inter-hospital consultation on adverse events.

DHBs that responded and were included in the survey were Auckland, Bay of Plenty, Canterbury, Capital & Coast, Counties-Manukau, Hawke's Bay & Chatham Islands, Lakes, MidCentral, Nelson & Marlborough, Northland, Otago, South Canterbury, Southland, Tairäwhiti, Taranaki, Waikato, Wairarapa, Waitematä, West Coast and Whanganui DHBs.

ENDS

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