24 March 2020
Amy S Van Wey Lovatt [FYI request #12201 email]
Tēnā koe Amy,
Re: OIA - adverse events - unauthorised access to restricted areas
Thank you for your request of 25 February 2020, requesting clarification of our original response
dated 21 February 2020.
In your original request for information, you asked:
“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”.
In response to your question, I said:
“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
You then asked, “Please explain to me by which mechanism incidents are reported and to whom”,
as per your second request for information.
The Health Quality & Safety Commission (the Commission) receives reports of adverse events
specifically related to receiving healthcare. An adverse event is described as an event which
results in harm or has the potential to result in harm to a consumer while they are receiving health
and disability services (see the Severity Assessment Code document attached in the link provided
above). All other adverse events that sit outside of services provided by health and disability
facilities would be reported to different agencies/organisations and would be managed under the
health and safety regulations. Health and safety events are required to be reported in accordance
with the Health and Safety at Work Act 2015 (and associated regulations). These events are not
within the scope of the Commission’s work.
As per my response to you of 21 February 2020, we define an incident as an event that involves
the health and safety of staff, volunteers, contractors, and visitors within health and disability
service providers, in the absence of the provision of health and disability services. Health and
safety events are not reported to the Commission. The National Adverse Events Reporting Policy
2017 specifically exclude occupational health and safety events.
Please clarify, is it the HQSC's assertion that
the HQSC doesn't have the information as to how incidents are supposed to be
reported, per response 1;
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";
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?
The Commission does not hold information on how health and safety incidents should
be reported. As per response 1 presented above these incidences are outside the
scope of the Commission work;
Incidents involving "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" do not meet the criteria outlined
in National Adverse Events Reporting Policy 2017, and are reported to the
Commission, as they do not involve the provision of health and disability services.
As per, response 1 the Commission does not hold this information as it is not reported
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.
Information on reporting health and safety events can be found on the WorkSafe New Zealand website.
As this information is publicly available, I am refusing your request under section 18 (d) of
the Official Information Act 1982.
I hope you find my responses helpful and provide a satisfactory answer to your queries.
Nāku noa, nā
Dr Janice Wilson