Reporting and reviewing adverse events involving consumers of mental health and addiction services

Introduction and background

In 2012, the mental health and addiction (MHA) sector advised the Health Quality & Safety Commission (the Commission) that the National Reportable Events Policy 2012 created issues for it. This resulted in the MHA sector and the Health Quality & Safety Commission (the Commission) collaborating on specific guidance.

With the release of the National Adverse Events Reporting Policy 2017, the 2012 guidance became redundant as the initial concerns were resolved in the updated policy.

As a result of the national MHA quality improvement programme’s learning from adverse events and consumer, family and whānau experience project, the MHA sector has asked for further clarification on how the National Adverse Events Reporting Policy applies to it.

This purpose of this document is to provide guidance to the MHA sector and clarify its obligations under the national policy.

Note: This is an interim document pending the update of the National Adverse Events Reporting Policy in 2022.

Adverse event review

1. All adverse event reporting, reviewing and learning systems should be based on the following principles as outlined in the national policy:

• Open communication
• Consumer participation
• Culturally appropriate review practices
• System changes
• Accountability
• Safe reporting.

2. All adverse events must be reported and reviewed as per the National Adverse Events Reporting Policy 2017. The 2017 policy allows providers to use a formal review method of their choice when reviewing adverse events. The expectation that providers use a root cause analysis (RCA) or a London Protocol no longer exists.

3. In summary, adverse event review consists of the following elements:

• Reporting – all severity assessment code (SAC) 1 and 2 events must be reported to the Commission (as per the National Adverse Events Reporting Policy 2017) and any other regulatory authorities as required.
• Triage – this is a preliminary process to determine the scope of the event and to select any appropriate further review method to use.
• Review – this involves using the agreed review method decided in the triage phase. The Commission recommends the use of the Learning Review methodology.
• National reporting – this includes specific recommendations about how to improve the care provided to consumers (locally or on a larger scale).

4. Triage process:

Many mental health and addiction services have a triage team (which may also be known as an oversight committee, adverse event steering group or some other similar name).

Before a triage team can make any decisions, a preliminary review needs to occur. This may be a file/desk review or some other local process.

The triage process allows organisations to prioritise resources to reviewing those adverse events that will provide the most learning for the organisation. All events must have a preliminary review and be triaged; however, the triage process can establish the level of further review each event may undergo.

During the preliminary review and triage process, the following questions may be helpful:

• Are there any ‘unknowns’ in relation to the event?
• Has there been any breach or deviation in policy or procedure?
• Are there system improvements to be gained?
• Do whānau and/or carers have any concerns regarding the event?[1]

Once the triage team has considered the information available, they will decide if the information already gathered is sufficient to make recommendations for system improvement or if a more detailed review needs to take place. It is important that triage team decisions follow the principles of the National Adverse Event Reporting Policy 2017 and consider the four preliminary review questions listed above.

5. Review process: Once an appropriate methodology has been selected and a review completed, the review team will make recommendations to improve the systems involved.

Update

Early in 2022, a toolkit for triaging, reviewing and learning from adverse events in mental health and addiction service was released.

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

The resources (links listed below) support health entities in adverse event reviews, including working with their 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

Click here to access the toolkit.

Questions and answers for MHA adverse events

How do I report and review suicides?

Inpatient suicides are those cases that involve suspected suicide by a current inpatient. This includes suspected suicide while on approved leave from an inpatient unit or having absconded from an inpatient unit. It also includes suspected suicide within 72 hours of discharge.

These cases require reporting as a SAC 1 to the Commission and a local review.

Outpatient suicides are those cases involving suspected suicide by an outpatient of MHA services or within 28 days of discharge from that service. These cases are to be reported to the Commission as a SAC 2 event (although they may be reported as a SAC 1 depending on specific circumstances) and require a review that reflects the circumstances (see below).

A service may choose to review and subsequently report to the Commission cases of outpatient suicide that occur outside the 28-day period if they think there is learning to be shared by reviewing.

What local review should I use for cases of suicide?

The National Adverse Event Reporting Policy 2017 allows providers to choose the most appropriate methodology to use. When considering which methodology to use, providers should consider the following questions:

• Are there any ‘unknowns’ in relation to the event?
• Has there been any breach or deviation in policy or procedure?
• Are there system improvements to be gained?
• Do whānau and/or carers have any concerns regarding the event?

(Originally published December 2021)

Endnotes

[1] Healthcare Improvement Scotland. 2019. Learning from Adverse Events through Reporting and Reviewing: A national framework for Scotland. Edinburgh: Healthcare Improvement Scotland. URL: www.healthcareimprovementscotland.org/our_work/governance_and_assurance/management_of_adverse_events/national_framework.aspx (accessed 11 February 2021).