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Learning from adverse events (report) 907.92 KB

The report covers adverse events reported by New Zealand's 20 district health boards (DHBs) and other providers. Adverse events (previously referred to as serious and sentinel events) are events which have generally resulted in harm to patients. This report details adverse events in DHBs in the year 1 July 2018 to 30 June 2019. It also provides suggestions for reducing the number of adverse events over the coming years.

Key findings:

Of the 916 reported adverse events:

  1. 566 were reported by DHBs
  2. 232 were reported from the mental health and addictions sector (DHBs only)
  3. 100 were reported by members of the NZ Private Surgical Hospitals Association
  4. Seven were reported by ambulance services
  5. Five were reported from the primary sector
  6. Five were reported by other providers
  7. One was reported from a hospice.

Actions for improvement:

  1. Continue to promote consumer engagement in adverse event reviews across the sector.
  2. Complete the research into whānau Māori experience of adverse events, and identify and recommend quality improvement initiatives.
  3. Seek to understand why Māori appear to be under-represented in adverse event reporting. 
  4. Continue to actively engage with the wider health and disability sector to embed the National Adverse Events Reporting Policy 2017 at a local level.
  5. Create a national repository of publicly accessible adverse events tools and resources.
  6. Consult on a national policy for open communication.
  7. Develop accessible education and training for providers across the health and disability sector.
  8. Incorporate restorative practice principles into existing adverse event workshops.
  9. Complete the introduction of the national adverse events database system across all DHBs.
  10. Seek to understand the barriers to completing adverse event reviews in a timely manner.
  11. Continue to work in collaboration with other agencies, such as the Accident Compensation Corporation (ACC) and the Health and Disability Commissioner (HDC), to reduce preventable harm in health care.
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