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Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau

Learning from adverse events and consumer, family and whānau experience

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).

Reviewing adverse events[1] 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.

Project extension

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. 

Restorative practice

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

References

[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.

Further resources

Last updated: 24th March 2022