Reporting from adverse events

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:

1. 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
2. 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. 

Learning from adverse events 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.

We will publish a summary of adverse events from 2019/20, which will be included in the Commission’s 2019/20 annual report and published on our website in November 2020.

The data will consist of:

• numbers of adverse events
• adverse events categorised by World Health Organization (WHO) codes
• demographic information
• always report and review events.

For the 2020/21 financial year we will publish national results quarterly, starting in May 2021. The results will be accompanied by commentary on developing themes. We also plan to publish additional reporting focused on in-depth thematic analyses of areas of concern and learning late 2021.

Copies of previous adverse events reports are available to download below.

Related Resources

• Publication: National summary of adverse events reported to the Health Quality & Safety Commission 1 July 2019 to 30 June 2020
• Publication: Learning from adverse events report 2018/19