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

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

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