Adverse events exception reporting 2020/21: Thematic analysis involving always report and review events
Always report and review (ARRs) events are events that can result in serious harm or death but are preventable with strong clinical and organisational systems. This thematic analysis reviewed all wrong consumer and wrong site ARRs reported to us by district health boards between 1 July 2017 and 30 June 2021. Using the Yorkshire Contributory Factors Framework, we grouped identified contributory factors and recommendations into broad themes.
Always report and review (ARRs) events are events that can result in serious harm or death but are preventable with strong clinical and organisational systems. This thematic analysis reviewed all wrong consumer and wrong site ARRs reported to us by district health boards between 1 July 2017 and 30 June 2021. Using the Yorkshire Contributory Factors Framework, we grouped identified contributory factors and recommendations into broad themes.
We found that the most commonly identified contributory factor was a failure to follow process, and the most commonly provided recommendations focused on reminding individuals to do better and making work more proscribed.
Based on the results of this analysis, the similar work carried out by the HSIB and the literature, we recommend that:
- Te Tāhū Hauora, in conjunction with the wider health and disability sector, reviews the events on the current ARR list and removes any events that do not have strong clinical or organisational systems available to prevent their occurrence
- Te Tāhū Hauora continues to support the health and disability sector to identify strong clinical or organisational systems for events where they do not yet exist, through promotion of the learning review tool and education and review of the national adverse event reporting policy.
