20 Aug 2015 | Adverse Events
The Health Quality & Safety Commission welcomed almost 50 adverse event reviewers to a workshop on 10–11 August 2015 at Ko Awatea in Auckland. The reviewers came from all over the greater Waikato and Northern region for a two-day deep dive into root cause analysis.
The workshop opened with a welcome from Dr Janice Wilson, chief executive of the Commission who asked participants to take what they learn and share it with their teams and colleagues.
Robyn Beattie and the Walker family set the scene for the day, sharing their experience following the death of their mother at Whanganui District Health Board (DHB) in 2013. Robyn described how participation in the review process enabled their family to get the answers they had been seeking about what had happened and why, while ensuring all avenues had been pursued and recommendations implemented to prevent the event happening again.
Participants also heard from Dr Denys Court of Auckland DHB on the essentials of open communication and Karen Vaughan from Nelson Marlborough DHB spoke about just culture.
The core of the workshop was led by Sandy Blake and Wendy Stanbrook-Mason of Whanganui DHB who demonstrated the step-by-step process of analysis, from building a team through to determining causal factors and all the challenges in between.
On day two Bob Henderson, an Air New Zealand pilot, Commission board member and human factors specialist, entertained and challenged participants, encouraging them to design systems with human fallibility in mind.
Finally Julie Paterson, chair of the Commission’s Adverse Events Learning programme expert advisory group and chief executive officer of Whanganui DHB, led a session on drafting recommendations and what it takes to ensure they are implemented by an organisation.
Two more courses will be held: