Learning from adverse events and consumer, family and whānau experience

Te ako mai i ngā pamamaetanga me to wheako tangata whaiora me to whānau | Learning from adverse events and consumer, family and whānau experience was a priority area within the seven-year mental health and addiction (MHA) quality improvement programme coordinated by Te Tāhū Hauora Health Quality & Safety Commission (Te Tāhū Hauora) that began in September 2019.

There are improvement opportunities for mental health and addiction services when reviewing adverse events, particularly in terms of learning from events to improve future care. Reviews could be less variable in their quality, and processes could be simplified and shortened to reduce the risk of extending the harm experienced by those involved.  

Tāngata whaiora (people seeking wellness), whānau and staff expressed a need for improvement, along with greater openness and inclusion in the adverse event review process.

The purpose of the Learning from adverse events and consumer, family and whānau experience quality improvement project was to partner with former district health board (DHB) teams in the MHA sector to look at ways to:

• improve the ability of organisations and the wider MHA sector to learn and heal from MHA adverse events [1]
• improve the experiences of consumers, family/whānau and staff involved in MHA adverse event reviews
• improve the safety culture for staff involved in MHA adverse event reviews.

The project has now ended, and the final report is available here.

 Te Whatu Ora entities will now provide ongoing oversight of these areas of activity.

Project overview:

1. Toolkit to assist health districts in learning from adverse events in the mental health and addiction sector

An important outcome of the project was a toolkit for triaging, reviewing and learning from adverse events in mental health and addiction services.

The toolkit aligns with the National Adverse Events Reporting Policy 2017.

The resources listed below support health district adverse event reviews, including working with non-governmental organisation (NGO) partners. 

• 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 MHA adverse event review methods, types, and approaches
• Output 3: Principles for engaging consumers and whānau in mental health and addiction adverse event reviews 
• Accompanying document: Reporting and reviewing adverse events involving consumers of mental health and addiction services 

2.  Pono videos about adverse events

Aimed at retelling the lived experiences of consumers, family and whānau, Te Tāhū Hauora MHA quality improvement programme team in recent years produced a series of pono videos (being true, valid, honest, genuine and sincere) to assist those in the MHA sector learn from adverse event incidents. 

• Anne-Marie Douglas shares her experience of mental health challenges that led to a review process.
• Nicola Peeperkoorn explores her family’s experience of the MHA event review process.

3. Restorative practice

Evidence has grown that restorative responses (restorative practice and hohou te rongo) have the potential to improve learning from adverse events and better meet the needs of consumers, whānau and staff.

The project focused on developing training opportunities in restorative responses for a small number of self-selected Te Whatu Ora project teams.

In partnership with subject matter experts from Te Ngāpara Centre for Restorative Practice Victoria University of Wellington, Te Tāhū Hauora Health delivered training on restorative responses over 12 months starting in May 2021.

Outcomes from this phase:

• As of March 2023, Te Tāhū Hauora has sponsored 60 people from the mental health and addiction (MHA) sector to attend the Restorative Foundations and Restorative Responses micro-credential courses offered by Te Ngāpara. Another 40 have been sponsored and are scheduled to complete by December 2023.

• The learning from adverse events and consumer, family and whānau experience project, with support from Te Tāhū Hauora leadership and capability and systems safety programmes, has provided the foundations for significant capability and capacity building in this area within the MHA sector.

• Some of the Te Whatu Ora project teams shared their experiences at the ‘Using restorative approaches to heal, learn and improve after harm’ national hui (meeting) held on 28 March 2023 to disseminate learning from their involvement with the project and support the ongoing growth in this area.

The updated ‘Healing, learning and improving from harm: National adverse events policy 2023 | Te whakaora, te ako me te whakapai ake i te kino: Te kaupapa here ā-motu mō ngā mahi tūkino 2023’,[2] effective 1 July 2023, now includes restorative responses as a principle.

Additionally, the Te Tāhū Hauora system safety and capability programme is continuing to support capability building in restorative responses in the MHA sector.

Find out more about Te Tāhū Hauora work with restorative practice here: Pou hihiri, pou o te aroha – Restorative practice.

Further resources

• Presentations and videos from the co-design workshop on learning from adverse events
• Presentations from learning session one of the Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project
• Presentations from the second co-design workshop for Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project
• Evidence review to inform development of the mental health and addiction quality improvement programme ‘Learning from adverse events and consumer experience’ project

References

[1] An adverse event is ‘an event with negative or unfavourable reactions or results that are unintended, unexpected or unplanned (also referred to as ‘incident’ or ‘reportable event’). In practice this is most often understood as an event which results in harm or has the potential to result in harm to a consumer’. See page 7 of: Health Quality & Safety Commission. 2017. National Adverse Events Reporting Policy. Wellington: Health Quality & Safety Commission. URL: www.hqsc.govt.nz/resources/resource-library/learning-from-adverse-events-report-201617.

[2] Health Quality & Safety Commission. 2023. Healing, learning and improving from harm: National adverse events policy 2023 | Te whakaora, te ako me te whakapai ake i te kino: Te kaupapa here ā-motu mō ngā mahi tūkino 2023. Wellington: Health Quality & Safety Commission. URL: www.hqsc.govt.nz/resources/resource-library/national-adverse-event-policy-2023.