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Online workshop looks at the review of mental health and addiction adverse events

Mental health & addiction quality improvement
18 April 2021

A virtual workshop was held recently for representatives from the mental health and addiction (MHA) sector about the essential components of a high-quality adverse event review.

Topics covered included the consumer experience, open communication, incident review processes, just culture, and crafting and implementing useful recommendations.

The workshop was attended by over 40 MHA representatives from 19 district health boards (DHBs) and one non-governmental organisation, and facilitated by the Health Quality & Safety Commission.

At the workshop, Hector Matthews, executive director, Māori and Pacific Health at Canterbury DHB, emphasised the importance of meeting the cultural needs of Māori in adverse event review. Key takeaway points were:

  • one size does not fit all – we need to understand the context and respond and adapt appropriately
  • consider having an advocate for the whānau to help navigate the adverse event process
  • meeting ‘kanohi-ki-te-kanohi’ (face-to-face) is often the best option
  • te reo Māori and tikanga Māori are the ‘pou’ (supports) of effective engagement
  • the hui process, based on traditional principles, is a powerful tool for engaging with whānau Māori and helps to rebuild trust through healing and reconciliation.

David Hughes, clinical lead of the adverse events learning programme at the Commission, discussed use of the severity assessment code (SAC) rating and triage tool for adverse events, types of review governance and different adverse event review methods with a focus on systems learning.

Jo Wailling, research fellow/facilitator at the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington, described the principles of a restorative approach to adverse events, which she said are guided by the concern to address harms, meet needs, restore trust and help those people affected.

Restorative practice is a voluntary process where all those who have been harmed by an adverse event come together to understand the impact and collaboratively decide what should be done to repair the harm and put things right.

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