Gisborne Hospital Report - Health and Disability Commissioner

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Gisborne Hospital 1999 – 2000 Incident Reporting and Complaints Procedure The consumers’ views 5.15 At the hui attended by my investigation team, comments were made by consumers about the Tairawhiti Healthcare complaints process. The Maori Health Manager reflected such complaints, saying that he “receives a lot of complaints from Maori about the manner in which they are treated at maternity services”. 5.16 A member of the Gisborne Health Committee advised that: “people will not come out and complain readily because the fear is someone will find out and they will not be treated”. She said it is a perceived fear because she has never known of any reprisals, but that fear is there, especially with Maori and Pacific Island people. 5.17 The Gisborne Health Committee reported that it has always been able to get appointments with the Chief Executive to discuss their concerns. The Committee has found that the senior managers do listen and minutes are taken “but the Committee is not sure if action is always taken”. The Committee sees its role as keeping community concerns on the agenda. 5.18 An advocate who was involved with the Cancer Society noted that “coastal patients with cancer are not referred [by Gisborne Hospital] for palliative care services from the Society. Newly diagnosed patients with cancer get missed and there are no formal referrals.” 5.19 Another hui attendee, who had formerly worked at Tairawhiti Healthcare, commented: 6. OPINION “The complaints process is not genuine or sincere and was set up to fail. Patients would attend meetings and then they would go nowhere. The complaint lives a short life and dies. The manager/s responsible managed and controlled the process and would use time to wait out the process so the complaint would go away. Complainants would still have ill feeling and would not feel like the matter was resolved. Kaumatua are often not up front, reluctant to complain or push the issue. The process is a genuine attempt to minimise problems in the organisation so the organisation does not have a bad image and nobody in the organisation is fingered as a bad performer.” Incident reporting 6.1 For incident reporting to be a significant tool at THL, all levels of the organisation need to be educated about the value of incident reports within an 59
Gisborne Hospital 1999 – 2000 Incident Reporting and Complaints Procedure effective hospital wide quality system. Starting with the Senior Management Group, there needs to be a demonstrated commitment to open discussion of incidents, identification of any trends, and development of achievable projects to address significant risks. 6.2 To minimise risk and maximise patient safety, staff at Gisborne Hospital need to experience the educative benefits of reporting incidents in a learning culture. They currently experience reporting incidents in a blaming culture. 6.3 The incident reporting process at Gisborne Hospital has become personalised. Staff interpret the completion of an incident form as a criticism against an individual staff member rather than an opportunity to improve patient safety. 6.4 Staff do not trust the current incident reporting system to address their concerns and have used other mechanisms, for example, the anonymous letter that was part of the background to this investigation. 6.5 An effective incident reporting system is one that captures all incidents or unintended events, including those that have resulted in injury, adverse events, potential incidents and “near misses”. 6.6 The capture of this information enables investigation of the root cause of the incident, monitoring of the extent to which it is occurring, and the taking of steps to reduce the risk of the incident recurring. 6.7 Awareness of the nature, causes and incidence of failures is a vital component of prevention. Low-level incidents or “near misses” can provide a useful pointer to more serious risks and can allow lessons to be learned before a major incident occurs. 6.8 There are two ways of viewing incidents or human error, the person centered approach, and the systems approach, with the former being the more commonly used. Quick judgements and the assignment of blame to individuals (which are characteristic of the person centered approach) obscure a more complex truth. Although a particular action or omission may be the immediate cause of an incident, closer analysis can reveal a series of events or departures from safe practice, each influenced by the working environment and the wider organisational context. 6.9 The process of investigating in-house incidents should be able to be carried out by in-house personnel without staff feeling there is a conflict of interest. THL does not have a Medical Director and at the time of the syringe incident did not have a Director of Nursing. An effective incident reporting system relies on people in key positions with the authority and mana to carry out an internal investigation. 6.10 Effective risk reduction means taking account of all the factors and changing the environment, as well as dealing with personal errors and omissions. This cannot take place in a culture where disciplinary considerations are always put first. Blame and disciplinary sanctions lead inevitably to defensive reactions, withholding of information and difficulty in ascertaining the facts. 60
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GISBORNE HOSPITAL 1999 - 2000 A rep
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Table of Contents Page Executive Su
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1. BACKGROUND EXECUTIVE SUMMARY 1.1
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3. THE ENVIRONMENT 3.1 My investiga
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pathologist, staff shortages and pr
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Gisborne Hospital 1999 - 2000 Intro
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RECOMMENDATIONS Quality Assurance S
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Gisborne Hospital 1999 - 2000 Recom
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Gisborne Hospital 1999 - 2000 Recom
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APPENDIX NZNO LETTER TO MINISTER OF
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11. The anaesthetist had a practice
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THE ANONYMOUS LETTER The anonymous
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GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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