Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Incident Reporting and Complaints Procedure
3.12 The policy states that the outcomes of incident reviews are not reported back
to the reporter in all cases but they are available (statement 13). No detail is
given of where they are available from and who can access them.
3.13 The incident reporting flowchart requires staff to determine whether
immediate notification of the appropriate staff member/manager is required.
No detail is given to assist staff to determine which incidents require
immediate notification (step 3).
3.14 The Incident and Complaint Management Policy lists a range of monthly and
quarterly reports that will be made to the Q&RMC, Core Quality Group
(CQG) and the Audit Committee. The CQG (which is the most senior quality
group of the organisation) is to receive a monthly summarised report of
complaints but not of incidents. Incidents are reported to the Q&RMC. The
policy provides no direction on the dissemination of report findings to staff.
3.15 Minutes of the CQG meeting of 16 August 1999 stated that there was still a
need to define “incident” and to clarify what needs to be reviewed and what
needs to be cumulatively reported. The revised Incident and Complaint
Management Policy was approved on 6 March 2000. The last two of these
requirements were not addressed in the newly approved policy and remain
outstanding.
4. PRACTICAL ISSUES RELATED TO INCIDENT REPORTING
Practical matters
4.1 A review of the documents, and discussions with staff, highlighted a number
of practical issues.
4.2 Categories have been introduced on the review form - for example, cultural
distress and contractor complaints - with no guidance as to their meaning. In
the absence of clear guidelines there may be inconsistent trend reports.
4.3 Incident forms are not printed with a number and, as a result, tracking can be
difficult. Both copies of the incident form are easily detachable and may
become separated en route to the Quality Co-ordinator’s office. The Quality
Co-ordinator commented that there is currently no mechanism to track filed
incident report forms and it cannot be guaranteed that they all arrive in her
office. An example of this is the initial incident form (October 1999)
regarding Dr Lucas’ reuse of syringes which was witnessed as being
completed and handed in to the Theatre Manager. However, the report was
never entered into the system and the Quality Co-ordinator had no record of
having received it.
4.4 The length of time between the completion of an incident form and review by
the reviewer was also identified as an issue in relation to the reuse of syringes.
The November 1999 incident form relating to Dr Lucas took three weeks to go
from the clinical area to the Quality Co-ordinator and then to the reviewer,
during which time additional risk could have been prevented.
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