Reviewing tragic events helps TDH improve its practices

31 October 2014

Tairawhiti District Health (TDH) has made changes to its pharmacy and maternity processes following investigations into two serious adverse events in the 2013/14 year, two fewer than the year before.

Following the release of the Health Quality & Safety Commission’s annual report on serious and sentinel events, TDH Chief Executive Jim Green said both events were awful for the families and individuals involved.

“Unfortunately things sometimes do go wrong in health. Unexpected complications happen and are often unavoidable however we also know that many are avoidable. As a District Health Board we have an obligation to learn from experience when things go wrong and to use what we learn to improve safety and quality.”

Commission Chair Professor Alan Merry says it is encouraging to see the work and resources the health sector has put into getting better at reporting incidents of patient harm. “Patients who are harmed during health care have a right to understand what happened and to expect that everything possible will be done to prevent the same thing from happening to someone else in the future.”

Prioritising the most at risk patients, and changes to how recommendations are made to patients taking blood thinning medications after surgery, are two of the changes that will be made as a result of investigation into an unexplained death at Gisborne Hospital following a planned surgery.

Learnings from the unexpected death of a three-day old baby has seen a focus on further improving team work and developing good communication practices in the maternity unit. This is reflected in the Maternity Quality & Safety Plan 2014/15.

Keeping the maternity unit fully staffed is a priority. To help with this TDH and WINTEC have developed a course to enable local people to train to be a midwife in Gisborne with just occasional trips to Waikato to undertake practicums that are not available in a smaller maternity unit such as TDH’s.

Mr Green said staff reviews of clinical care, as well as incidents and adverse events, while sometimes tragic for the individuals and families involved, provide lessons, information, and the chance to promote change and best practice.

“In both these cases we have made every effort to find out the root causes and apply our learning to the areas where they have occurred.”  

The two incidents reported at TDH were:

Unexpected death following planned surgery

As a result of the investigation:

  • Policy to be developed relating to the re-commencement of a specific blood thinning medication, called dabigatran, following surgery. The policy will be progressed within the reducing perioperative harm project that TDH is participating in and is coordinated by the Health Quality Safety Commission under the National Patient Safety Campaign.

  • TDH Pharmacy to review their Medication Reconciliation policy and practice. The communication processes and content between Pharmacist and House Surgeon; Pharmacist and Consultant when there is significant change/s to therapy will be reviewed.

  • Pharmacy now has regular peer reviews of medicine reconciliation process to ensure consistency and quality issues can be promptly addressed. Pharmacy are moving to a team approach with a prioritisation tool. This will see the percentage of patients Pharmacists see increase and the most critical patients are prioritised.

Unexpected death of a baby 3 days after delivery

As a result of the investigation:

  • Maternity Consultation and Transfer of Care Policy revised version developed and used in practice.

  • Teamwork training and good communication practices implemented as outlined in the Maternity Quality & Safety Plan 2014/15. An example of this is the Practical Obstetric Multi-professional Training course.

  • An accountability framework will be developed to further foster a fair and just culture

  • Focus on recruitment and development of secondary care workforce

  • Developed a course to enable local people to train to be a midwife in Gisborne with just occasional trips to Waikato

Frequently asked questions about serious adverse events.

ENDS