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Updated national adverse events policy released

13 February 2023

The updated national adverse events policy was today released to health sector providers ahead of implementation effective from 1 July 2023.

The policy is reviewed every five years by the Health Quality & Safety Commission (the Commission).

The aim of the policy, Healing, learning and improving from harm: National adverse events policy 2023 | Te whakaora, te ako me te whakapai ake i te kino: Te kaupapa here ā-motu mō ngā mahi tūkino 2023, is to improve consumer and health care worker safety by supporting organisations to heal, learn and improve following harm that occurs in health and disability services.

‘What’s different about the new policy is that it embeds Te Tiriti o Waitangi and a te ao Māori worldview and emphasises the focus on relationships through whānau engagement, equity, restorative practice and hohou te rongo restorative responses,’ Commission chief executive Janice Wilson said.

‘The policy focuses on a “systems safety” approach to health care, which looks at wider system factors that influence care to identify solutions that support future care.’

Dr Wilson says a change to learning, healing and improving from ‘harm’ is a feature of the new policy.

‘In practice, this involves taking a relational approach when responding to harm to better understand and meet the needs of all in the system and provide opportunities to restore wellbeing and implement actions that enhance safety and future relationships.’

Dr Wilson says the policy was developed during 2022 and involved a Commission-led co-design process with a national working rōpū that included health and disability sector representatives from across the country.

Feedback from these groups was incorporated into the policy along with input from a wider sector including the Commission’s Board, Te Rōpū Māori (the Commission’s Māori advisory board) and the national Consumer Advisory Group.

A critical analysis was also undertaken to ensure the Commission’s commitment to Te Tiriti was captured and mātauranga Māori included.

The Commission will undertake a national roadshow from March 2023 to familiarise providers with the policy and guide the development of support resources.

Read the new policy document here