Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Recommendations
10. Consideration should be given to confidential (but not anonymous) reporting of
“adverse events” or “near misses” until the culture of fear changes.
11. Feedback should be sought and utilised from users of the system. Staff
satisfaction with the incident reporting system should be formally monitored at
designated timeframes.
12. A system-centred approach should be initiated, rather than a personcentred/blaming
approach.
13. Support people should be welcome at incident review discussions.
14. The education of staff on the incident reporting system (at orientation and
thereafter on a regular basis) should be reviewed so that staff are clear about the
philosophy behind incident reporting.
15. All staff groups should receive sufficient education to gain a clear understanding
of the incident reporting system and their responsibilities within it.
16. A standardised education programme for all staff groups should be implemented
as an urgent priority at Tairawhiti District Health.
17. The process for incident review should be clearly defined.
18. Staff delegated incident review responsibility should receive appropriate
education for the role.
19. Monitoring should be introduced with a focus on ensuring that serious failures are
not recurring.
20. All evaluation methods listed in the Incident and Complaint Management Policy
should be implemented: ie, monthly reports to the Quality and Risk Management
Committee and Core Quality Group, and quarterly reports to the Audit
Committee.
21. “Near misses” should be reported and analysed to identify common factors and
causes.
22. Accountabilities for monitoring incident trends should be clarified and clear
processes established to ensure accountability. (The Quality and Risk
Management Committee is currently responsible for the regular monitoring and
improvement of the incident reporting system. The Committee’s responsibility
for monitoring the outcomes from the system is less clear.)
23. The Clinical Board should establish a timetable (eg, three monthly) for analysing
reported incidents across Tairawhiti District Health with a view to discerning
trends.
24. The Clinical Board should be given responsibility for monitoring the
implementation of action plans designed to address organisational trends
identified in clinical incidents.
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