Adverse Events
Reporting adverse events nationally signifies an important step on the road to improving health outcomes for New Zealanders.

The key is to improve safety by encouraging open and transparent reporting of incidents when something goes wrong.

The intention of the report is to support DHBs' continuous quality improvement focusing on shared learning to move towards improving systems and minimising the possibility of future incidents.


Visit the Health Quality and Safety Commission website for more information.


The following are the most recent events investigated and their outcomes:


Event summary



What happened?

An 85-year-old man developed a pressure injury to his left heel during his hospital admission for a right leg, above knee amputation. This injury was assessed by the wound care nurse specialist and required advanced wound care dressings. The injury has since healed.


What did we find?

An investigation found that the patient had been assessed as being at high risk for developing a pressure injury however, an individualised care plane was not put in place to manage this risk. Nurses failed to document that daily skin assessments had been carried out.


What did we do?

We have reiterated the pressure injury prevention standards to all nursing staff and now conduct a weekly audit of patient’s clinical records to ensure that these standards are met. A nurse educator receives all incident reports relating to pressure injuries and ensures that individualised care plans are in place.