Adverse events (previously known as serious and sentinel events) are events which have generally resulted in harm to patients.
An adverse event is an event with negative reactions or results that are unintended, unexpected or unplanned (often referred to as ‘incidents’ or ‘reportable events’). In practice this is most often understood as an event which results in harm to a consumer.
A near miss is an event which, under different circumstances, could have caused harm to a consumer but did not, and which is indistinguishable from an adverse event in all but outcome.
Reporting adverse events
Under the National Adverse Events Reporting Policy 2017, health and disability service providers with obligations under the Health and Disability Services (Safety) Act 2001, and those who voluntarily comply, are expected to:
- report serious adverse events (severity assessment code (SAC) rating 1 and 2) and events on the Always Report and Review list to the Commission, using the adverse event brief – part A reporting form. This report should be made within 15 working days of notification of the event to the provider
- undertake formal review of serious adverse events (SAC 1 and 2) and events on the Always Report and Review list and send review findings and recommendations to the Commission, using the adverse event brief – part B reporting form. This report should be made within 70 working days of notification of the event to the provider.
Reporting forms need to be signed off by the organisational chief executive (or equivalent) or senior delegate on their behalf before sending to the Commission.
Consumers and their whānau who have been involved in the event should be offered the opportunity to share their story as part of the review process and review findings and recommendations should be shared with them.
Adverse event reports
The Commission’s role is to promote a nationally consistent approach to reporting, review and learning and to share lessons learned nationally and across the health and disability sector.
The Commission produces a report on adverse events each year, based on information provided by District Health Boards and other providers. Links to these reports are available below.