Adverse events exception reporting 2020/21: Thematic analysis involving Māori and Pacific peoples

Māori experience the poorest health outcomes across the total population of Aotearoa New Zealand with more Māori than non-Māori/non-Pacific people experiencing in-hospital adverse events. To look beyond the numbers and types of events reported, Te Tāhū Hauora Health Quality & Safety Commission completed a thematic analysis of reported events for Māori and Pacific peoples.

This paper presents a thematic analysis of severity assessment code (SAC)-1 and 2 adverse events involving Māori and Pacific peoples reported to Te Tāhū Hauora from 1 July 2017 to 30 June 2021. It aimed to identify how organisations have considered quality improvement opportunities and to examine the pathways to implement those improvements rather than to look at why adverse events occur across the health sector.

This thematic analysis has outlined challenges for Te Tāhū Hauora and health service providers who report adverse events to consider. It has also allowed Te Tāhū Hauora to look at how information/data is collected and what changes are required to investigate whether avenues for quality improvement are considered when offering mitigating strategies for all adverse events.

There is real opportunity to use the AEB part B information to identify and track how system-focused quality improvement is considered and implemented. Te Tāhū Hauora plans to take advantage of this opportunity, make suggested changes and report shared learnings.