Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Incident Reporting and Complaints Procedure
interchangeably, but adverse events are more correctly identified as a subset of
incidents, where actual harm has resulted. An “adverse event” is:
“Any unintended event or circumstance caused by healthcare
management rather than a disease process, which leads to
hospitalisation, prolonged hospital stay, morbidity at discharge, or
death.” (Brennan, TA, et al, Incidence of adverse events and negligence
in hospitalized patients. N Eng J Med. 1991;324:370-84)
An “incident” is:
“Any event or circumstance which could have or did harm anyone or
that could lead to a complaint. It may or may not have been preventable
and may or may not have involved an error on the part of the health care
team.” (Australian Patient Safety Foundation, 2000)
3.6 The definition in Tairawhiti Healthcare’s incident reporting policy refers to
internally reported events that may potentially have resulted in harm, loss or
damage, ie, a “near miss”. However, no reference is made to a “near miss” in
the text of the policy, and the incident report form does not include “near
miss” as a category.
3.7 The text of the Incident and Complaint Management Policy combines
statements on incidents and complaints, and is difficult to follow.
3.8 The incident review form asks for incidents to be categorised as 1, 2, or 3.
These categories are not defined or explained on the review form or in the
policy statement. The policy gives no guidance on the type or severity of
incident to be reported. Less serious incidents reported ranged from the loss of
a TV aerial to refusal to pay for a meal allowance.
3.9 The Incident and Complaint Management Policy states that some incidents
may not require review (statement 7). No formal definition or criteria are
given to guide the Quality Co-ordinator on which incidents are to be managed
by that office as opposed to requiring review external to the Quality Coordinator’s
office. This lack of detail also makes it difficult for staff to know
which incidents they can anticipate may require such review. A transparent
process has the potential to reduce staff members’ fear of the system.
3.10 The policy requires incidents that need tracing and review to be sent to the
appropriate staff member (statement 8). However, no indication is given as to
what level of staff may be delegated responsibility for reviewing incidents, so
it is difficult to target education effectively.
3.11 Guidelines are given in the policy on the action to be taken if complaints are
not resolved within the 14 day time period (statement 10). The Q&RMC is
delegated responsibility for monitoring the implementation of
recommendations made as a result of incident investigation (statement 11).
The investigation team found no evidence of this occurring.
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