Can we make our hospitals safer for patients,
clinicians and managers?

The results of a recent ACC-funded survey of all DHBs regarding
their policies and practices for handling patient injury/adverse events.

Presented by

Professor Emeritus Laurence Malcolm
(University of Otago)

Pauline Barnett Senior Lecturer
(Department of Public Health and General Practice)

The full ACC Report prepared by Laurence and Pauline.

A small but highly intelligent group enjoyed the hospitality of Eurest (NZ) at the Botanic Gardens Cafe followed by Laurence Malcolm FCHSE and Pauline Barnett presenting their findings on disclosure of adverse events in health.

The presentation launched with some common clinical scenarios that highlighted the dilemmas - what if you know that no one will ever find out? What if the adverse event has not effected the patient? They then went on to outline the paper from Walshe and Shortell that examined the barriers to disclosure for clinicians which highlighted the similarities across all countries.

The extent of the problem was brought into context with the figures that the US 1999 IOM report showed that the effects of unintended injury resulting from hospital care were the equivalent of 2 x 747 crashes every 3 days = 1 x 9/11 every two weeks. Closer to home the work of Peter Davis has concluded that patients with adverse events stayed an additional 9.3 days, ie took up 14.3% of all bed days and that nearly 50% of these were preventable - to quote "Preventable adverse events have a major impact on patient outcomes and extent of hospital stay. A substantial proportion of these are system related and, hence, in principle susceptible to quality improvement."

Imagine if we could reduce bed stay by 7%!

All is not doom and gloom. The Commonwealth Fund study of consumer perceived quality 2001 overall rating and responsiveness showed that New Zealanders rate their system as higher in quality and higher in physician responsiveness than Australia, Canada, the UK and the USA. Laurence asked the question again regarding the interest of the media in such "good news" stories.

The results of the ACC study were then presented which showed all DHBs working towards better disclosure the successes and difficulties encountered. Pointers for encouraging and supporting disclosure were given.

At the conclusion a lively discussion was led off by Dr Nigel Millar and many "stories from the front lines" were shared.

An excellent presentation which deserved a wider audience.
 

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This event was made possible by the generous support of