The best way of improving quality and safety in New Zealand hospitals is to learn from the serious and sentinel events that occur each year, according to the New Zealand Nurses Organisation (NZNO).

The organisation has congratulated the Health Quality and Safety Commission on Making our Hospitals Safer, its report of serious and sentinel events reported by district health boards (DHBs) in 2010/11. The report reveals that 377 serious or sentinel events took place in public hospitals, with falls accounting for 52 per cent of all the serious and sentinel events in the year 2010/11. There were 195 falls reported, up from 130 in the previous year, 85 in the 2008/09 year and 56 in the 2007/08 year. The increase in falls fuelled the overall increase in serious and sentinel events, up from 318 in the previous year.

NZNO's quality spokesperson, professional nursing adviser Kate Weston, said the increase in falls was very concerning. "Falls are a direct result of not having enough adequately skilled and qualified nursing staff on the floor to manage the falls risk. Some DHBs, in an attempt to meet budget constraints, have abandoned their policy of providing a special watch for those at high risk of falls," she said.

"Falls prevention initiatives should be multidisciplinary but nurses, because they are the health professionals with patients 24/7, have the key role to play in reducing patient falls. So it is imperative there are enough nurses on the floor to meet patients' needs."

Weston said there was compelling international evidence which showed that when nursing positions were lost, nursing-sensitive indicators such as patient falls, skin tears and pressure ulcers, increased.

"We will be monitoring this trend in the Commission's future reports, particularly in relation to the Safe Staffing Health Workplace Unit's work on care capacity demand management. Essentially, this means having the right number of the right staff in the right place at the right time. When there are enough appropriately skilled staff to provide care and supervision to patients at risk of falls, the number of falls reported by DHBS will undoubtedly decrease," Weston said.

She congratulated the DHBs, profiled in the Commission's report, that were working on falls prevention initiatives.

Referring to the other two major causes of serious and sentinel events, clinical management events (29 per cent, N=108) and medication events (seven per cent, N=25), Weston said that accurate and timely communication among all the health professionals involved in a patient's care was critical to reducing these events.

"NZNO wants to work with the Commission to ensure the quality improvements needed to reduce serious and sentinel events are put in place. This is nurses' business."

The report pointed out that more than 2.7 million people are treated in New Zealand public hospitals each year.