Adverse Events - Unauthorized access to restricted areas

Amy S Van Wey Lovatt made this Official Information request to Health Quality and Safety Commission

Health Quality and Safety Commission did not have the information requested.

From: Amy S Van Wey Lovatt

Dear Health Quality and Safety Commission,

I am writing to you as a New Zealand citizen.

Request 1:
Would it be accurate to say that any event which occurred at a DHB and which had a risk of causing harm to a patient, employee or member of the public would be considered an "adverse event", "incident" or "near miss", which would require reporting? This would include, but not be limited to actions which have a risk of causing physical harm or emotional harm, such as deliberate actions which delayed diagnosis or breached patient privacy.

Request 2:
Would you be able to direct me to a comprehensive list or description of what is considered "adverse events", "incidents" or "near misses" by the HQSC?

Request 3:
Would unauthorized access, by a member of the general public, to restricted areas such as a surgical theater or medical laboratory, where bio-hazardous materials are kept and diagnostic testing conducted, be considered an "adverse event", "incident" or "near miss" and if so, please either describe or provide the protocol that DHB's are required to follow if such an event were to occur.

Request 4:
Please provide me with the number of reported incidents, for each individual DHB, in which a member of the public gained access to a surgical theater without authorization or having been accompanied by a DHB employee, for each of the years from 2016 to 2019, inclusive, and the outcomes of these incidents.

Request 5:
Please provide me with the number of reported incidents, for each individual DHB, in which a member of the public gained access to a medical laboratory, where bio-hazardous materials are kept and diagnostic testing conducted, without authorization or having been accompanied by a DHB employee, for each of the years from 2016 to 2019, inclusive, and the outcomes of these incidents.

Request 6:
In the event that a DHB had reported unauthorized access to a surgical theater or medical laboratory, what category of "adverse event" or "incident" would they be reported under in a DHB's Learning from Adverse Events report?

Request 7:
Please provide me with the steps taken by each DHB to mitigate the risk of unauthorized access to surgical theaters and medical laboratories.

Thank you very much for your assistance in this matter.

Kindest regards,

Amy S Van Wey Lovatt

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From: Tina Simcock
Health Quality and Safety Commission


Attachment HQSC124 Amy S Van Wey Lovatt acknowledgement letter.pdf
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Dear Amy

Thank you for your email and subsequent information request within. Attached is our acknowledgement letter alongside advice that we will respond to your request on or before the 9 March 2020.

Kind regards

Tina Simcock
Senior Advisor Planning and Accountability
Health Quality & Safety Commission
T: 04 901 6067
M: 021 820 210
E: [email address]

www.hqsc.govt.nz | www.open.hqsc.govt.nz

       
This electronic mail message, together with any attachments, is confidential. If you are not the intended recipient, please e-mail us immediately and destroy this message. You may not copy, disclose or use the contents in any way. Thank you.

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From: Lisa Clyde
Health Quality and Safety Commission


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[1]Values signature graphic 2018

Dr Janice Wilson

Chief Executive Officer

Health Quality & Safety Commission

DDI: 04 9016050 | [mobile number]

E: [2][email address]

 

[3]www.hqsc.govt.nz | [4]www.open.hqsc.govt.nz

 

 

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From: Amy S Van Wey Lovatt

Dear Lisa Clyde,

I would like to thank the HQSC for their timely response to my OIA request; however, I am a little confused by the response I received and respectfully request the HQSC clarify their statements.

My first request was:
Would it be accurate to say that any event which occurred at a DHB and which had a risk of causing harm to a patient, employee or member of the public would be considered an "adverse event", "incident" or "near miss", which would require reporting? This would include, but not be limited to actions which have a risk of causing physical harm or emotional harm, such as deliberate actions which delayed diagnosis or breached patient privacy.

The response from the HQSC was: Yes. The Commission only receives reports involving adverse events and some near misses, as set out in the National Adverse Events Reporting Policy 2017. Incidents are reported via different mechanisms.

This response means that any event that had a "risk of causing harm to a patient, employee or member of the public" including "actions which have a risk of causing physical harm or emotional harm, such as deliberate actions which delayed diagnosis or breached patient privacy" are reported either through a National Adverse Events Reporting Policy or the Incident reporting mechanism.

Request 1: Please explain to me by which mechanism incidents are reported and to whom.

Later in the responses, to my requests, the HQSC stated that "unauthorized access, by a member of the general public, to restricted areas such as a surgical theatre or medical laboratory, where bio-hazardous materials are kept and diagnostic testing conducted" would be considered "incidents". Yet, the HQSC stated that "The Commission does not hold any information on specific protocols that DHBs are required to follow in such an event."

This seems to be inconsistent with the HQSC response 1, where the HQSC stated "Incidents are reported via different mechanisms", thus not under the National Adverse Events Reporting Policy 2017, but "near misses" are.

Request 2:
Please clarify, is it the HQSC's assertion that
(i) the HQSC doesn't have the information as to how incidents are supposed to be reported, per response 1;
(ii) that such incidents in which "unauthorized access, by a member of the general public, to restricted areas such as a surgical theatre or medical laboratory, where bio-hazardous materials are kept and diagnostic testing conducted" would not meet the threshold of reporting, even though they are clearly events which have "a risk of causing harm to a patient, employee or member of the public" and are "actions which have a risk of causing physical harm or emotional harm, such as deliberate actions which delayed diagnosis or breached patient privacy";
(iii) does the information not exist because no events such as "unauthorized access, by a member of the general public, to restricted areas such as a surgical theatre or medical laboratory, where bio-hazardous materials are kept and diagnostic testing conducted" have been reported to either the HQSC under the National Adverse Events Reporting Policy 2017 or "reported via different mechanisms", as per the HQSC first response?

Request 3:
I respectfully request that the HQSC assist me in finding the requested information, pursuant to sections 13 and 14 of the OIA, even if this requires transferring my OIA request to an appropriate agency or agencies.

Thank you again for your assistance in this matter.

Kind regards,

Amy S Van Wey Lovatt

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From: Tina Simcock
Health Quality and Safety Commission


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Kia ora Amy, we have received a further request from you for additional
information. We have classed this as a new request and have attached
acknowledgement to that effect.

 

I will get back to you soon.

 

Kind regards

 

 

Tina Simcock

Senior Advisor Planning and Accountability

Health Quality & Safety Commission

T: 04 901 6067

M: 021 820 210

E: [1][email address]

 

[2]www.hqsc.govt.nz | [3]www.open.hqsc.govt.nz

 

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confidential. If you are not the intended recipient, please e-mail us
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From: Amy S Van Wey Lovatt

Dear Tina Simcock,

Thank you very much for your acknowledgement and for looking a bit deeper for the answers to my OIA request. I look forward to your timely response.

Yours sincerely,

Amy S Van Wey Lovatt

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From: Tina Simcock
Health Quality and Safety Commission


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Kia ora Amy

 

The attached letter is notification that we require an extension until the
9 April (we may be able to do it earlier subject to consultation outcome)
to complete this OIA for you.

 

Please note, if we can complete it before the 9 April, we will do so.

 

We appreciate your patience.

 

Kind regards

 

 

Tina Simcock

Senior Advisor Planning and Accountability

Health Quality & Safety Commission

T: 04 901 6067

M: 021 820 210

E: [1][email address]

 

[2]www.hqsc.govt.nz | [3]www.open.hqsc.govt.nz

 

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From: Janice Wilson
Health Quality and Safety Commission


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[1]CO00010_Email_Sign_v2

Dr Janice Wilson

Chief Executive Officer

Health Quality & Safety Commission

DDI: 04 9016050 | [mobile number]

E: [2][email address]

 

[3]www.hqsc.govt.nz | [4]www.open.hqsc.govt.nz

 

 

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This electronic mail message, together with any attachments, is
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the contents in any way. Thank you.

 

 

 

 

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