Learning from adverse events and consumer, family and whānau experience
Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau
Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau
Te ako mai i ngā pamamaetanga me to wheako tangata whaiora me to whānau | Learning from adverse events and consumer, family and whānau experience was a priority area within the seven-year mental health and addiction (MHA) quality improvement programme coordinated by Te Tāhū Hauora Health Quality & Safety Commission (Te Tāhū Hauora) that began in September 2019.
There are improvement opportunities for mental health and addiction services when reviewing adverse events, particularly in terms of learning from events to improve future care. Reviews could be less variable in their quality, and processes could be simplified and shortened to reduce the risk of extending the harm experienced by those involved.
Tāngata whaiora (people seeking wellness), whānau and staff expressed a need for improvement, along with greater openness and inclusion in the adverse event review process.
The purpose of the Learning from adverse events and consumer, family and whānau experience quality improvement project was to partner with former district health board (DHB) teams in the MHA sector to look at ways to:
The project has now ended, and the final report is available here.
Te Whatu Ora entities will now provide ongoing oversight of these areas of activity.
1. Toolkit to assist health districts in learning from adverse events in the mental health and addiction sector
An important outcome of the project was a toolkit for triaging, reviewing and learning from adverse events in mental health and addiction services.
The toolkit aligns with the National Adverse Events Reporting Policy 2017.
The resources listed below support health district adverse event reviews, including working with non-governmental organisation (NGO) partners.
2. Pono videos about adverse events
Aimed at retelling the lived experiences of consumers, family and whānau, Te Tāhū Hauora MHA quality improvement programme team in recent years produced a series of pono videos (being true, valid, honest, genuine and sincere) to assist those in the MHA sector learn from adverse event incidents.
3. Restorative practice
Evidence has grown that restorative responses (restorative practice and hohou te rongo) have the potential to improve learning from adverse events and better meet the needs of consumers, whānau and staff.
The project focused on developing training opportunities in restorative responses for a small number of self-selected Te Whatu Ora project teams.
In partnership with subject matter experts from Te Ngāpara Centre for Restorative Practice Victoria University of Wellington, Te Tāhū Hauora Health delivered training on restorative responses over 12 months starting in May 2021.
Outcomes from this phase:
The learning from adverse events and consumer, family and whānau experience project, with support from Te Tāhū Hauora leadership and capability and systems safety programmes, has provided the foundations for significant capability and capacity building in this area within the MHA sector.
The updated ‘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’,[2] effective 1 July 2023, now includes restorative responses as a principle.
Additionally, the Te Tāhū Hauora system safety and capability programme is continuing to support capability building in restorative responses in the MHA sector.
Find out more about Te Tāhū Hauora work with restorative practice here: Pou hihiri, pou o te aroha – Restorative practice.
[1] An adverse event is ‘an event with negative or unfavourable reactions or results that are unintended, unexpected or unplanned (also referred to as ‘incident’ or ‘reportable event’). In practice this is most often understood as an event which results in harm or has the potential to result in harm to a consumer’. See page 7 of: Health Quality & Safety Commission. 2017. National Adverse Events Reporting Policy. Wellington: Health Quality & Safety Commission. URL: www.hqsc.govt.nz/resources/resource-library/learning-from-adverse-events-report-201617.
[2] Health Quality & Safety Commission. 2023. 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. Wellington: Health Quality & Safety Commission. URL: www.hqsc.govt.nz/resources/resource-library/national-adverse-event-policy-2023.