Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Incident Reporting and Complaints Procedure
4.25 THL advised that Clinical Directors receive reports through the Clinical Board
and SMG, and they are required to provide feedback to staff and their services.
4.26 Staff recall receiving feedback previously on incident findings, for example by
way of a bulletin to the wards and staff cafeteria. Staff found this feedback
very valuable.
4.27 The Quality Co-ordinator has identified the need for staff feedback and is
currently establishing a timeframe to implement monthly reports to individual
services. The expectation is that once individual services receive these reports
they will report back to the Quality Co-ordinator on what has been put in place
as a result of information in the report.
4.28 The incident forms reviewed frequently lacked one or more of the following:
• date
• hospital number
• ward
• patient sticker
• time
• incident description.
One form contained only a date, signature and the question “anaesthetic
protocols required?”
4.29 The Quality Co-ordinator expressed concern that there is over-reporting of
non-serious incidents and under-reporting of serious incidents. The
effectiveness of the incident reporting system is influenced by staff knowledge
of the system and their responsibilities.
Internal reviews of the incident reporting system
4.30 Interviewees described two major reviews of the incident reporting system.
One involved a roundtable discussion including senior managers and
occupational health staff on how the incident reporting system could be
improved. A series of actions were identified.
4.31 The Human Resources Manager and the Quality Co-ordinator, in consultation
with the Senior Management Group and the Q&RMC, carried out the more
recent review. The apparent intention was to address gaps in the policy.
There was no evidence, however, of a formal process (eg, focus groups or a
survey form) for seeking feedback from a wide range of users on the
effectiveness of the system.
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