Each year district health boards (DHBs) are required to release information about the serious adverse events that have occurred within their hospitals.

A serious adverse event is an incident that has resulted in a need for further significant additional treatment, major loss of function, is life threatening or has led to an unexpected death.

DHBs review these events and report them to the Health, Quality & Safety Commission (HQSC). The HQSC then collates this information for its annual report of all DHB serious adverse events.


How we report and review adverse events

Nelson Marlborough Health has robust systems in place to report many types of events.

As well as reporting adverse events we report events which may not cause long-lasting harm and 'near misses' where there was risk of harm, rather than harm actually occurring.

This enables us to have a greater overview of all events, regardless of their severity. It enables us to investigate the context and circumstances of an incident, to recognise any recurring themes and to identify opportunities to make improvements.

Our reporting systems contribute to a culture of transparency and an environment of trust for the people who use our services. It also supports our continuous quality improvement approach.

Each reported adverse event involves a person suffering harm or death while in our care.

At Nelson Marlborough Health we work openly with patients, service users, family/whanau and staff during our investigation of adverse events. We acknowledge the distress and grief they experience when things go wrong.


Serious adverse events reports