Toolkit released to help DHBs learn from mental health and addiction sector adverse events

The Health Quality & Safety Commission has released a toolkit for triaging, reviewing and learning from adverse events in mental health and addiction services. Links are at the bottom of this page.  

An adverse event is an event with negative or unfavourable results that are unintended, unexpected or unplanned.   

The project, Te ako mai i ngā pāmamaetanga me te wheako tāngata whai ora me te whānau | Learning from adverse events and consumer, family and whānau, focuses on the experiences of tangata whai ora and their whānau.    

The toolkit is designed to support district health boards (DHBs) in adverse event reviews, including working with their non-governmental organisation (NGO) partners.   

Learning from consumers, whānau and staff

The project is one of five priority areas of the seven-year national mental health and addiction quality improvement programme coordinated by the Health Quality & Safety Commission.   

DHB-led project teams started work on this project in September 2019. During a six-month co-design phase, they heard from consumers, whānau and staff about their experiences of the mental health and addiction adverse events review process, what is working and what can be improved.   

The working group

As part of the project, a working group was established to develop a knowledge package/toolkit for triaging, reviewing and learning from adverse events in mental health and addiction services aligned with the National Adverse Events Reporting Policy 2017. 

The group was co-chaired by mental health and addiction quality improvement programme clinical lead Dr Clive Bensemann and Dr Peri Renison and comprised mental health and addiction sector leaders, subject matter experts in the field of adverse events, NGO and consumer representatives.   

The outputs

The working group met monthly from June to December 2020 with sub-groups formed to work on four agreed outputs:   

•  Output 1: Mental health and addiction Severity Assessment Code (SAC) examples 2021–22  
• Output 1a: Always Report and Review list 2021–22  
• Output 2: Overview of mental health and addiction adverse event review methods, types and approaches  
• Output 3: Principles for engaging consumers and whānau in mental health and addiction adverse event reviews  

There is also an accompanying resource, Reporting and reviewing adverse events involving consumers of MHA services, which guides the mental health and addiction sector and clarifies its obligations under the National Adverse Events Reporting Policy. Note: This is an interim resource pending the update of the National Adverse Events Reporting Policy in 2022.   

These outputs have been through an extensive internal and external consultation process over the past 12 months (beginning February 2021).