Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Incident Reporting and Complaints Procedure
Staff can ask for feedback on the incident reports and THL should not be
criticised if they fail to, or elect not to, do so.”
4.17 It should be noted that the new incident reporting form clearly provides a
space for staff to indicate they want feedback.
Incident analysis and reporting
4.18 The reporting and analysis of incidents is essential if the data gathered in the
incident reporting process is to be used effectively as a learning tool to prevent
recurrence of the risk.
4.19 THL’s progress towards meeting the reporting requirements outlined in the
Incident and Complaint Management Policy was unclear. The requirements
are monthly reports to the Q&RMC and CQG, and quarterly reports to the
Audit Committee.
4.20 Differing views were expressed on the type of reports the Q&RMC was
receiving. One member of the committee stated that the committee was
receiving reports including summaries. The Quality Co-ordinator commented
that the committee received graphs to identify trends but no summaries of
events or incidents. The Quality Co-ordinator’s view is “that there should be a
summary of incidents and a report on where to from here to follow through
and ensure the incident does not happen again”. Of course, incident reporting
cannot provide definitive information on trends, since it is dependent upon the
comprehensiveness and accuracy of the reporting.
4.21 It is apparent from the interviews and reports available to the investigation
team that the framework outlined in the policy is not yet in place. Monthly
reports are not submitted to the Q&RMC and as at September 2000 only two
quarterly reports (December 1999 and March 2000) had been produced. The
format of the two quarterly reports varies and there is no breakdown of what is
included in the category of patient incidents. In light of this, the Q&RMC role
in monitoring and discussing incidents as outlined above would not have been
achievable.
4.22 In addition, there is a lack of follow-up on incomplete reports. The process for
this was described by the Quality Co-ordinator as “informal” and as a task to
be achieved.
4.23 The extent to which incident trend reports presented to the Q&RMC are
disseminated to staff is unclear. Copies of these quarterly reports are not
distributed to individual services. The Quality Co-ordinator noted that “while
there is nothing to prevent these reports being passed on to staff there is
nothing currently in place requiring this to occur”. Her general feeling was
that they are not passed on.
4.24 The Quality Co-ordinator also stated that she was unsure if the reports went to
the Clinical Board, as she understood they do not currently have a role in
relation to incidents.
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