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Adverse Event Management

Purpose / name of service applies a systematic approach to adverse, unplanned and untoward events to ensure that such situations are managed in a transparent manner. The analysis of the events will be used to continuously improve the services provided.
Scope / This document applies to allname of service service users and where relevant their family/whānau.
Other adverse event processes are included in the following policies and procedures:



References
Type / Title
Policies/
Procedures / Health and SafetyManual
Infection Prevention and Control Manual/Plan
Complaints Management
Medication Management
Quality Framework
Death of a Service User
Legislation /
  • Health & Safety in Employment Act 1992
  • Mental Health (Compulsory Assessment and Treatment) Act
  • Accident Insurance Act 1998
  • Accident Compensation Act 1992
  • Health Act 1956
  • Coroners Act 2006
  • Health and Disability Services (Safety) Act 2001
  • Health Practitioners Competence Assurance Act 2003
  • Fire Safety and Evacuation of Buildings Regulations 2006

Documents/
Guidelines /
  • Sentinel Events Workbook
  • Guidelines for managing risk in healthcare
  • Guidance to open disclosure policies
  • CARM – adverse medication response reporting
  • New Zealand Health and Disability National Reportable Events Policy
  • Reporting and reviewing adverse events involving users of mental health services
  • Reportable Events Guideline
  • New Zealand Incident Management System

Standards /
  • NZS 8134:2008, Health and Disability Services Standards

Definitions( NZ Health Quality and Safety Commission)
Adverse Event / An adverse event is an incident which results in harm to a service user.
Accident / Within the context of this document: an event resulting in personal injury as the result of an incident (accident is a generic term for an‘incident serious harm’ or an ‘incident’ where actual harm occurred).
Central repository / The Health Quality & Safety Commission which is the central point for collecting,
analysing and disseminating learnings from reportable events.
Incident / An incident is any event that could have or did cause harm to a service user.
Near miss incident / An incident which under different circumstances could have caused harm to a service user but did not, and which is indistinguishable from an adverse event in all but outcome.
SAC / Severity assessment code
Serious incident review / This term refers to the type of review conducted for serious and sentinel mental health events.
Reportable event / Any adverse event classified as a SAC 1 or SAC 2 rating (serious incident/sentinel event).
RCA / Root cause analysis: a formal process of investigation designed to identify the root causes of adverse events.
Open Disclosure / Open disclosure, or open communication, refers to the timely and transparent approach to communicating with, engaging with and supporting service users, their families and whānau when things go wrong.
Abbreviations
EAICR / Adverse Events Incident Complaint Record
SIR / Service Improvement Request

Consultation

Group/Role / Date
Version: / V1 / Issue Date / 160714 / Created by: / GSHarnisch
Review Date / 010717 / Authorised by: / NRA Working Group