Document facilitator: Patient Safety Coordinator
Senior document owner: CCDHB CEO
Document number: 1.8723
Issue Date 8 March 2019
Review Date 8 March 2024
Type:
Policy
Name:
Adverse Event and Incident Management
Purpose
The purpose of this policy is to articulate how all adverse events and health and
safety incidents are managed at Capital & Coast District Health Board (CCDHB).
Policy Statement
CCDHB aims for a
just culture where employees are not blamed for system failings
and feel comfortable disclosing adverse events and incidents. The fundamental role
of an adverse events reporting system is to enhance safety by learning from adverse
events and near misses that occur in health and disability services. Adverse events
and incidents will be reviewed and managed in a professional and respectful manner
that ensures lessons are learnt, to improve quality and safety for patients and their
family/whānau and employees.
These practices comply with legislative requirements:
The New Zealand Health and Disability Services (CORE) Standards (2008)
HDC Code of Rights The
Health & Safety at Work Act (2015)
Health & Disability Services (Safety) Act (2001)
Privacy Act (1993), the Health Information Code (1994), and the DHB
General Disposal Authority
Scope
Includes:
All CCDHB employees (permanent, temporary and casual), visiting medical
officers and practitioners, students and other partners in care
All clinical adverse events and incidents (including good catches) that occur
or have the potential to occur to any person as a result of the provision of
health and disability services (managed in alignment with the National
Adverse Events Reporting Policy 2017)
Health and safety events affecting any employee, contractor or volunteer
(managed under the Health and Safety at Work Act (2015).
Excludes:
Employment relationship issues and events; these are managed under the
Employment Relations Act (2000), and should be referred to Human
Resources.
Incidents involving a criminal act, use of illicit drugs or alcohol, deliberate
unsafe action or deliberate patient harm should be referred to Human
Resources.
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capitalDocs ID 1.8723
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Document facilitator: Patient Safety Coordinator
Senior document owner: CCDHB CEO
Document number: 1.8723
Issue Date 8 March 2019
Review Date 8 March 2024
Principles
CCDHB supports the principles that underpin the National Adverse Events Reporting
Policy (HQSC 2017) for clinical adverse events. These include:
open communication
consumer participation
culturally appropriate review practice
system changes
accountability
reporting must be safe
Definitions
Clinical/non-clinical
Clinical events are those that affect patients/consumers during an episode of care.
Non-clinical events are those that do not directly involve patient care.
Good catch (near miss)
An event which under different circumstances could have caused harm, but did not,
and which is indistinguishable from an incident in all but outcome.
Incident
An event with potential or actual negative or unfavourable reactions or results that
are unintended, unexpected or unplanned (also referred to as
adverse event or
reportable event).
Just Culture – (No blame)
One in which employees are comfortable
disclosing errors
, including their own, while
maintaining accountability. It recognises individual practitioners should not be held
accountable for system failings over which they have no control, yet does not tolerate
conscious disregard of clear risks to patients or gross misconduct.
Notifiable Event
When any of the following occurs as a result of a work accident: a death, notifiable
illness or injury.
Open communication
The timely and transparent approach to communicating with, engaging with and
supporting consumers, their families and whānau when clinical incidents occur.
Review
A formal process that is carried out to analyse an incident or good catch and develop
recommendations based on the findings.
SQUARE
Safety Quality and Reportable Events electronic reporting system (RL 6) where
incidents are reported
Third Party Administrator (TPA)
An organization that processes and handles ACC claims for an employer (e.g. Wellnz
- manages ACC claims for CCDHB)
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capitalDocs ID 1.8723
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Document facilitator: Patient Safety Coordinator
Senior document owner: CCDHB CEO
Document number: 1.8723
Issue Date 8 March 2019
Review Date 8 March 2024
Role and responsibilities
Role
Accountability and Responsibility
All CCDHB
Report all incidents using SQUARE. For a clinical event, this should also be
employees
documented in the patient’s clinical record
Business Manager
Provide expert advice, support and leadership in relation to the management
on-call, or
and reporting of adverse events and incidents after hours
Afterhours Duty
Nurse Manager
Charge Managers
Ensure staff are aware of their responsibilities in relation to incident
and Clinical
management.
Leaders
Manage, monitor and review incidents within areas of delegated
responsibility and implement corrective actions from reviews
Participate in reviews of clinical severe/major incidents and Always Report &
Review list 2018-19 (HQSC, 2017) in conjunction with the quality teams.
Chief Executive
Overall management responsibility for the DHB’s safety processes in relation
to clinical and non-clinical incidents and adverse events
Clinical
Governance for implementation and compliance with this policy
Governance Board
Oversight of the management of clinical adverse events
Director of Area
Reports patient deaths as required under Section 132 of the Mental Health
Mental Health
Act (1992)
Directorate
Oversight across their directorate including service incident and adverse
Executive Directors
event data, compliance, analysis, trends and risk identification and
management
Responsibility to ensure compliance with policy within their directorate for
reporting, reviewing reportable events and implementation of corrective
actions
Directorate Quality
Provide support and expertise with review and management of incidents and
Teams
adverse events with the purpose of highlighting where systems, processes,
human factors, policy, or procedure could be improved; emerging trends;
and/or where further change is required.
Provide
adverse event and incident management education to
managers/senior staff
Support open communication process
Oversight of trends emerging from adverse events and incidents
Executive
Strategic oversight of all events and incidents
Leadership Team
Executive Director
Ensure training for review of incidents and adverse events
QIPS
Support the identification of areas for quality improvement, particularly in
relation to patient care
Supports the clinical adverse events reporting and reviewing system
General Manager
Strategic oversight of non-clinical incidents, work injury rates and notifiable
Corporate Services
events
General Manager
Strategic oversight of clinical incidents and adverse event reviews and
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Document facilitator: Patient Safety Coordinator
Senior document owner: CCDHB CEO
Document number: 1.8723
Issue Date 8 March 2019
Review Date 8 March 2024
QIPS
management processes
Maintain a system of reporting and reviewing clinical adverse events which
engages with consumers and aligns with National Adverse Events policy
(HQSC 2017)
Health & Safety
Review of health and safety events where an employee or other person was
Service
seriously harmed
Notification of work related injuries resulting in treatment to TPA
Assist and support managers with incident investigation
Report notifiable events to WorkSafe
Medical Staff
Coroners notification, notifiable diseases, ACC treatment injuries
Non-clinical
Ensure all reporting staff are aware of their responsibilities in relation to
Managers
incident management.
Manage, monitor and review incidents within areas of delegated
responsibility and implement corrective actions from reviews
Operations
Ensure oversight of service compliance, data analysis and risk management
Managers
Inform directorate executive management of serious adverse events.
Patient Safety
Develops organisational learnings from patient safety issues
Coordinator
Strengthens the patient safety culture through the development and
coordination of relevant patient safety projects
Monitors compliance with the National Adverse Events Reporting policy
Provides monthly reports to HHS, annual serious adverse events report and
facilitates reporting SAC 1&2 and
Always Report and Review events to the
HQSC.
The Board
Governance oversight of DHB safety in relation to adverse events and
incident management
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capitalDocs ID 1.8723
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Patient Safety Coordinator
Senior document owner: CCDHB CEO
Document number: 1.8723
Issue Date 8 March 2019
Review Date 8 March 2024
External Reporting Requirements
Incident Description
Reporting Agency
Always Report Events and SAC 1&2 Clinical
Health Quality & Safety Commission (HQSC)
Incidents
Deaths that must be reported under Section 13 (2) 2
Coroner
& 3 Coroners Act (2006)
Notifiable Diseases under the Health Act (1956)
Medical Officer of Health, Ministry of Health
Treatment injuries
ACC
Employee work related ACC injury
TPA
Death, notifiable illness, injury or incident
Worksafe
occurring as a result of work (Notifiable Event)
Unintended adverse reaction to medicine,
Centre of Adverse Reactions Monitoring
psychoactive substances, recreational substance and (CARM)
legal high substances
Incidents related to quality of medicines or medical
Medsafe, Ministry of Health
devices
Any incident or situation that puts at risk (or
Director General, Ministry of Health
potentially could put at risk) the health or safety of the
people for whom the service is being provided.
Any investigation commenced by a member of the
police into any aspects of the service.
Any death of a person to whom you have provided
services, or occurring in any premises in which
services are provided, that is required to be reported
to a Coroner under the Coroner’s Act (2006)
Events relating to misadministration of radioactive
Office of Radiation Safety, Ministry of Health
material
CCDHB-related Documents
Risk management policy policy
Health and safety policy policy
First Aid at Work procedure
Control of Contractors procedure
2DHB Workplace rehabilitation Procedure – under review
Clinical Adverse Event procedure – under review
CCDHB Consequence Table – under review
Adverse Event and Incident Management Page 5 of 6
capitalDocs ID 1.8723
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Patient Safety Coordinator
Senior document owner: CCDHB CEO
Document number: 1.8723
Issue Date 8 March 2019
Review Date 8 March 2024
References
Health and Disability Services (CORE) Standards (2008)
Health Quality & Safety Commission (June 2017). National Adverse Events
Reporting Policy 2017: New Zealand health and disability services.
HQSC (December 2012). Serious Incidents involving users of Mental Health
services.
Occupational Health and Safety Management Systems – specification with guidance
for use (2001). Standards New Zealand and Standards Australia
Legislation
The documentation, notification and disclosure of incidents are subject to the
following legislation:
Coroners Act 2006
Health Act (1956)
Health and Disability Commissioner Act 1994
Health and Disability Services (Safety) Act 2001
Health and Safety at Work Act (2015)
Health Practitioners Competence Assurance Act 2003
Injury Prevention Rehabilitation and Compensation Act 2001
Mental Health Compulsory Assessment and Treatment Act 1992
Accident Compensation Act 2001
Disclaimer: This document has been developed by Capital & Coast District
Health Board (CCDHB) specifically for its own use. Use of this document and any
reliance on the information contained therein by any third party is at their own risk
and CCDHB assumes no responsibility whatsoever.
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