Event Reporting and Management
Type: Policy
HDSS Certification Standard
Issued by: Executive Leadership Team
Version 1.0
Applicable to: Hutt Valley DHB
Contact person: Policy Facilitator
Lead DHB: Hutt Valley DHB
1. Introduction
This policy’s aim is to ensure all events (incidents, accidents, and near misses/good catches) are
reported, analysed and managed in a consistent, supportive and professional manner. Hutt Valley
DHB has adopted the Health Quality and Safety Commission’s (HQSC) National Adverse Events Policy
2017 as the basis for this document (
appendix 1).
The purpose of this policy is to improve the quality, safety and experience of health and disability
services through systems that:
• are safe
• are consumer and whānau-centred
• provide for early identification and review of adverse events
• ensure lessons are learnt so that the risk of repeating preventable adverse events is
minimised
• demonstrate public accountability and transparency
Hutt Valley DHB views events, both clinical and non-clinical, as opportunities for systems and
process improvement. Event reporting and management are fundamental to continuous quality
improvement and risk minimisation.
2. Policy
• All events, incidents, accidents and good catches/near misses will be reported and managed
in accordance with the procedures defined in this document.
• Events will be recorded online on the Adverse (reportable) Events reporting system
(SQuARE) within specified timeframes (
refer to SQuARE manual).
• Staff with defined responsibilities, as outlined in this policy, will ensure prompt and effective
follow up occurs for each reported event.
• The severity of an adverse event is determined using the SAC Rating and Triage Tool
(A
ppendix 2).
• All consumer related events rated SAC1 or SAC2 and “Always Report and Review” (A
ppendix
3) events will be reviewed and reported to the Health Quality & Safety Commission HQSC by
the Quality Service Improvement & Innovation Team (QSII)
. All events should be rated on
the actual outcome for the consumer.
• All events reported will be used for trend analysis and may be used as basis for quality
improvement activities.
_______________________________________________________________________________________________________
Document author: Quality Advisor
Authorised by: Executive Leadership Team
Issue date: January 2018
Review date: January 2021
Date first issued: January 2018
Document ID: QR003
Page 1 of 6
CONTROLLED DOCUMENT – The electronic version is the most up to date version. The DHB accepts no responsibility for
the consequences that may arise from using out of date printed copies of this document.
3. Scope
This policy applies to all persons working within Hutt Valley DHB, including contractors, sub
contractors and students.
Exclusions:
• Consumer complaints not related to healthcare incidents (refer Hutt Valley DHB Feedback
policy) NB: Where a complaint includes notification of an incident this should be reported and
reviewed according to this policy.
• Contractor complaints that do not involve Hutt Valley DHB (refer to contractor’s own process).
• Employee complaints or sensitive incidents not related to patient care or treatment (refer to
the relevant Human Resources policy).
• Employee relationship issues.
4. Open Disclosure
Consumers and their whānau are entitled to truthful and open communication at all times following
an adverse event. Hutt Valley DHB requires open communication with consumers and their families
as part of normal care and services. When a patient / consumer suffers harm, or potential harm, as
a result of a mistake or an error whilst under the care of the DHB, the circumstances associated with
the event must be fully explained to them in an open and transparent manner i.e. open disclosure.
Information about an event that causes harm, or potential harm, must be given to the patient
and/or their support person as soon as practicable after the event is identified, in a culturally
appropriate manner, and by an appropriately skilled staff member. Exceptions may occur when the
information is likely to prejudice the physical or mental health of the individual (this decision is made
in conjunction with the appropriate clinical staff).
A patient and/or their support person must be informed where:
• They have suffered harm directly or indirectly as a result of care
• Harm is possible though not yet evident (i.e. potential consequences not already discussed)
• There is no harm; however under different circumstances the event could have caused harm
and the information about the event could be seen as relevant to their care
The patient and/or support person can expect to:
• have an open and honest discussion and be fully informed of the facts surrounding an event
where harm, or potential harm, has occurred and the consequences of that harm
• receive an acknowledgement of what has happened
• be treated with empathy, respect and consideration in a culturally appropriate manner
• be provided with relevant ongoing care, management or rehabilitation, support as necessary
and in a manner appropriate to their needs
• receive information regarding further management or rehabilitation as a result of harm
caused, including given access to, and assistance with, an ACC treatment injury claim if
appropriate
• be advised of, have input to, and be fully informed as to the outcome of any investigation or
review undertaken, together with any changes instituted as a result of that investigation
Hutt Valley DHB’s expectation is that the patient and/or support person / whānau must receive an
honest and genuine apology for any harm caused as soon as practicable. If required, seek advice /
support from senior staff or the QSII team.
_______________________________________________________________________________________________________
Document author: Quality Advisor
Authorised by: Executive Leadership Team
Issue date: January 2018
Review date: January 2021
Date first issued: January 2018
Document ID: QR003
Page 2 of 6
CONTROLLED DOCUMENT – The electronic version is the most up to date version. The DHB accepts no responsibility for
the consequences that may arise from using out of date printed copies of this document.
5. Adverse (reportable) Events
5.1 Definitions:
Adverse Event
• An event with negative or unfavourable reactions or results that are unintended,
unexpected or unplanned i.e. an event that results in harm or has the potential to result in
harm to a patient/consumer, visitor, employee
• Reflects an unsatisfactory situation in terms of the quality of clinical practice, quality of
operational management, or quality of service delivery systems
• Results in, or could have resulted in, loss or damage to property relating to consumers,
visitors or employees or the organisation
• Results in, or could have resulted in, loss or damage to the environment
• Could have (near miss/good catch) caused harm, serious harm, damage or loss if:
(i) the situation had not been retrieved in time to prevent harm occurring; or
(ii) employees foresee that a recurrence of the event could result in harm
Severe / Major Event:
• actual permanent harm or death
• actual service delivery disruption
• actual risk to reputation
• actual risk of legal action.
Moderate Event:
• potential permanent harm or death
• potential service delivery disruption
• potential risk to reputation
• potential risk of legal action
Minor / Minimal
• minimal potential permanent harm or death
• minimal potential service delivery disruption
• minimal potential risk to reputation
• minimal potential risk of legal action
Always Report and Review Event: an adverse event that can result in serious harm or death but is
preventable with strong clinical and organisational systems e.g. wrong knee procedure;
administration of incorrect blood product; retained swab following surgical procedure - (
Always
Report and Review list (
appendix 3 - NB this not an exhaustive list). These events can highlight
weaknesses in management of fundamental safety processes
5.2
If an event involves any of the following:
• a criminal act;
• the use of illicit drugs / alcohol by an employee;
• a deliberate unsafe act;
• deliberate patient harm;
_______________________________________________________________________________________________________
Document author: Quality Advisor
Authorised by: Executive Leadership Team
Issue date: January 2018
Review date: January 2021
Date first issued: January 2018
Document ID: QR003
Page 3 of 6
CONTROLLED DOCUMENT – The electronic version is the most up to date version. The DHB accepts no responsibility for
the consequences that may arise from using out of date printed copies of this document.
the matter should be referred to the Service Manager (SM) / Service Group Manager (SGM) /
Executive Leadership Team (ELT) / Human Resources (HR) and legal advice should be sought.
Management of the adverse event and any performance management processes must be clearly
separated.
5.3
Procedure for Managing an Adverse Event
All events must be reported within the shift the event occurred using the Adverse Events Reporting
system (SQuARE) by the staff member:
• who first becomes aware of the event; or
• who is most involved in the event; or
• to whom an event is notified
The Clinical Nurse Manager (CNM)/Team Leader (TL) is accountable for:
• Notification to SM / SGM as soon as possible if event is severe or major
• Initial assessment, review and investigation of the reported event within 72 hours of the
event occurring. However if an event occurs over a weekend, the review process may be
extended. Review and investigation will include:
-
actual contributing factors
-
improvement actions required, by whom and by when;
-
review/discussion with Clinical Head of Department (CHOD) and SM /or SGM
The SM / SGM of the service is accountable for:
• Ensuring that their staff are supported as required
• Determining if escalation is needed to the Chief Executive (CE) / ELT / Chief Medical Officer
(CMO) (if yes, escalate as soon as possible)
• Determining if further review is required and engaging with the QSII team as required
• Ensuring that where an organisational-wide issue is identified by an event, the matter is
communicated to other relevant services
• Identifying service-based trends and initiating improvements to prevent reoccurrence.
5.4 Patient / Consumer Events
•
Ensure the patient’s / consumer’s immediate needs have been dealt with appropriately.
•
Communicate the circumstances around the event to the patient / consumer (and family /
whānau where appropriate). It is prudent to consider appointing a liaison person.
Guidance/advice can be obtained from the CNM, After Hours Manager, SGM, SM, Duty
Manager (DM), CMO and/or Executive Director of Nursing/Midwifery (EDON/EDOM),
Executive Director Allied Scientific & Technical (EDAHST), or QSII team.
NB: Following initial notification via SQuARE, mental health events are investigated and reviewed by
the Mental Health Addictions and Intellectual Disability Service 3 DHB (MHAIDS 3DHB) and are
reported back to Hutt Valley DHB once the review is completed.
Staff are accountable for:
•
reporting events to their line manager (eg CNM/TL)
•
reporting the event on SQuARE within the shift the event occurred
_______________________________________________________________________________________________________
Document author: Quality Advisor
Authorised by: Executive Leadership Team
Issue date: January 2018
Review date: January 2021
Date first issued: January 2018
Document ID: QR003
Page 4 of 6
CONTROLLED DOCUMENT – The electronic version is the most up to date version. The DHB accepts no responsibility for
the consequences that may arise from using out of date printed copies of this document.
•
Documenting the event in the clinical notes including immediate actions taken, information
provided to the patient / consumer or family / whānau and recording the SQuARE event
number in the clinical notes.
5.5 Employee Related Event
•
Provide immediate care
and treatment of the staff member affected
•
All staff are responsible for ensuring that their co-workers receive appropriate medical
assistance if required. Seek advice/discuss with the CHOD. Refer to the emergency
department as appropriate.
•
Blood or body fluid accidents must be reported immediately to the direct manager before
the matter is referred to Occupational Health and Safety (refer to Blood/Body Substance and
Fluid Exposure Policy). If the event occurs outside of normal hours, the After Hours
Management team must be informed in the first instance.
The CNM / TL is:
• accountable for investigating each incident to determine whether it was caused by or arose
from a significant hazard.
• responsible for working with the Occupational Health and Safety Department and their team
for taking action to minimise or eliminate that hazard where appropriate (refer Managing
Notifiable Events guidance). Where hazard control is involved, the hazard register of that
ward or unit must be updated.
6 Severe and Major Events
6.
1
Procedure for Managing a Severe or Major Event within Business Hours
The service lead where the event has occurred must notify relevant SM / SGM immediately. The SM
/ SGM will inform the ELT immediately or within 24 hours ie:
•
Chief Executive / Chief Operating Officer
•
Chief Medical Officer
•
Executive Director of Nursing/Director of Midwifery
•
Executive Director of Allied Health, Scientific and Technical
•
General Manager, Quality Service Improvement & Innovation
(
appendix 4)
NB: Following initial notification via SQuARE, mental health events are investigated and reviewed by
the Mental Health Addictions and Intellectual Disability Service 3 DHB (MHAIDS 3DHB) and are
reported back to Hutt Valley DHB once the review is completed.
6.2
Procedure for Managing a Severe or Major event outside Business Hours
The service lead where the event has occurred must immediately inform the After Hours Manager,
who will subsequently inform the Duty Manager. The duty manager will inform relevant SM/SGM
and ELT members within 24 hours of event occurring.
•
The Duty Manager or After Hours Manager will ensure that statements are taken from those
staff involved in the event. This should be done within 48 hours after the event. Appropriate
support should be provided to staff.
NB: Following initial notification via SQuARE, mental health events are investigated and reviewed by
the Mental Health Addictions and Intellectual Disability Service 3 DHB (MHAIDS 3DHB) and are
reported back to Hutt Valley DHB once the review is completed.
_______________________________________________________________________________________________________
Document author: Quality Advisor
Authorised by: Executive Leadership Team
Issue date: January 2018
Review date: January 2021
Date first issued: January 2018
Document ID: QR003
Page 5 of 6
CONTROLLED DOCUMENT – The electronic version is the most up to date version. The DHB accepts no responsibility for
the consequences that may arise from using out of date printed copies of this document.
7 Information to Employees
Employees are to be provided with feedback about adverse events when requested. This will
include:
•
Feed-back to the reporting individual by their manager if practical
•
Feed-back to employees generally on the actions taken to address concerns raised through
the reportable events system
8 External Reporting Requirements
•
Hutt Valley DHB is required to report all consumer related severe or major events and
always report and review events to the Health Quality & Safety Commission (HQSC). An
Adverse Event Brief (AEB) Part A must be submitted to the HQSC within 15 days of the event
occurring. A final review report (AEB Part B) must be provided to HQSC within 70 working
days. The QSII team will submit AEB reports to the HQSC.
•
Mental health events that meet the following criteria are required to be reported to the
Director of Mental Health:
• Notifications of patient deaths in accordance with s.132 MH (CAT) Act 1992.
Patients are further defined as either; a person required to undergo assessment
under s.11 or s.13; a person subject to a compulsory treatment order; or a
special patient.
• Adverse events involving special patients. This includes attempted suicide,
absent without leave (AWOL), assault, and breach of leave conditions (eg alcohol
use).
• Any adverse events likely to draw media attention.
A notification to the Director of Mental Health (DoMH) must be completed and sent to the
Director within 14 days of an event occurring. The DoMH reporting process is managed by
the Mental Health Addictions and Intellectual Disability Service 3DHB (MHAIDS) and the
Director of Area Mental Health Services (DAMHS).
•
Worksafe NZ requires any organisation to notify it of any notifiable events that arise from a
work related incident - (see Managing Notifiable Events guidance on the Occupational
Health & Safety Policy page on the intranet)
_______________________________________________________________________________________________________
Document author: Quality Advisor
Authorised by: Executive Leadership Team
Issue date: January 2018
Review date: January 2021
Date first issued: January 2018
Document ID: QR003
Page 6 of 6
CONTROLLED DOCUMENT – The electronic version is the most up to date version. The DHB accepts no responsibility for
the consequences that may arise from using out of date printed copies of this document.
