A reader from New Zealand writes to inform me of the second annual report by the New Zealand health service on serious and sentinel events in that country's hospitals. Here it is.
I was taken by some quotes from Patrick Snedden, Chair of the Quality Improvement Committee:
Sometimes, despite people’s best efforts, things go wrong. When they do, we need to be open with patients and their families, do what we can to correct the situation and we need to support the clinicians and health professionals involved.
We also need to investigate impartially, learn what happened and – most of all –we need to share the information try to stop it happening again.
Hospitals have always collected this data. Last year we learned more about the value of sharing lessons learned with other DHBs (District Health Boards) and have therefore started to introduce a new, national incident management framework to record the incidents and provide detailed summaries of outcomes and lessons learned.
Our aim is to improve safety by encouraging open and transparent reporting of events when something goes wrong. What we’re learning is being translated to system and process improvements in hospitals to reduce the risk of these events.
We have good, safe hospitals staffed by highly skilled people that provide a good quality of care – this is about making it even better.
I was also struck by the Maori saying at the top of the report, which I have used for the title of this posting. It means: A small contribution can be as valuable as a precious stone.