Reviewing adverse events and learning from these reviews is one of the five priority areas of the national mental health and addiction (MHA) quality improvement programme, coordinated by the Health Quality & Safety Commission (the Commission).
The programme uses a quality improvement approach to enhance health services so people receive high-quality care and support.
Opportunities for improvement
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 have expressed a need for improvement, along with greater openness and inclusion in the adverse event review process.
The ‘Learning from adverse events and consumer, family and whānau experience’ project has been underway since early 2019. Preliminary workshops were held with the mental health and addiction sector in March and June of that year. The project was due to end in July 2020 but was extended to November 2020 at the request of district health board (DHB) project teams.
The Commission’s goal is to work with DHB-led project teams to learn from when things go wrong and the impact that has on tāngata whaiora, whānau and staff, to help prevent these adverse events happening again.
Toolkit released to assist DHBs in learning from adverse events in the mental health and addiction sector
One outcome of this project is the toolkit for triaging, reviewing and learning from adverse events in mental health and addiction services, which was released on 28 February 2022.
The toolkit aligns with the National Adverse Events Reporting Policy 2017.
The resources (links listed below) support DHBs in adverse event reviews, including working with their non-governmental organisation (NGO) partners.
Pono videos about adverse events
These pono (being true, valid, honest, genuine and sincere) videos are produced by the Health Quality & Safety Commission (the Commission) mental health and addiction (MHA) quality improvement team.
Through the retelling of the lived experiences of consumers, family and whānau, pono videos aim to assist those in the MHA sector to learn from adverse event incidents.
Clinically, an adverse event is an event with negative or unfavourable reactions or results that are unintended, unexpected or unplanned.
In practice, an adverse event is one that results in, or has the potential to result in, harm to a consumer. For instance, a consumer’s attempt to take their own life would be viewed as an adverse event.
Under the Commission’s National Adverse Events Reporting Policy 2017, health and disability providers must report adverse events that result in serious harm or death to the Commission, who then begin a review process.
Phase two of this project began in May 2021 and involves working with four DHB project teams, in partnership with the team from Te Ngāpara Centre for Restorative Practice, Victoria University of Wellington, to explore the restorative practice approach further.
Find out more about the Commission’s work with restorative practice here: Pou hihiri, pou o te aroha – Restorative practice
 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.