Improving Quality Logo.

Quality Improvement & Innovation

Reportable Events - Questions and Answers

What is changing with regard to reporting events?

DHBs are asked to change the way in which they report the occurrence of serious, sentinel, SAC 1 and SAC 2 events.

The new arrangements will involve:

reporting on specific incidents within five working days of their occurrence, to a central events reporting function at the Ministry of Health – the Reportable Events Brief form is available for downloading
quarterly reporting to the same centralised function, on consolidated data events that have occurred in that quarter - each quarter, the Ministry will send to the DHBs a consolidated list of events that they have received during the previous quarter, for confirmation of the accuracy of the data and to have additional follow up information added.

The draft National Policy for the Management of Healthcare Incidents September 2008 provides the method for the Severity Assessment Code (SAC) scoring (pp37-38) – available from www.moh.govt.nz/moh.nsf/indexmh/improvingquality-reportableevents-resources

What is the ‘go live’ date for the new reporting arrangements?

From 1 July 2009, all events (serious, sentinel, SAC 1, SAC 2) will be reported by DHBs to the centralised events reporting function.

The first quarterly reports will be available for validation by DHBs soon after the close of the 1 July- 30 September 2009 quarter.

Why is the quarterly validation of data necessary?

The quarterly validation of consolidated data will allow a quality check for the data gathered, prior to any reporting to Ministers or the public. It will also provide DHBs with an opportunity to update information about specific incidents, such as actions that have been completed and whether the event investigation is now closed.

What are the benefits of reporting events to the central repository?

Reporting to a central repository of data ensures:

a more coordinated national approach to the monitoring
analysis and reporting of trends in incidents
a greater sharing of lessons learned in managing incidents
the consequences of incidents are mitigated
the risk of future events is reduced
that clusters of events and trends can be identified earlier due to the larger data set.

Currently, incident-related data is reported from a number of sources (eg. DHBs, ACC, the Office of the Health and Disability Commissioner, the Coroner). The information has not been collated into a single system. This makes collating comprehensive analysis, reports, and learnings for the sector a difficult task.
Establishing a national reporting function for reportable events will provide the health sector with up to date data and analysis from hospitals (and eventually other health organisations) across New Zealand.

How do I report an event?

An event can be reported by completing the Reportable Event Brief (REB) form. The REB is emailed or faxed to the reportable events administrator within five working days of the event’s occurrence.

At the end of each quarter DHBs will be sent a summary spread sheet with the details of each event reported. Each DHB will need to add details of the event investigation (eg. confirm what recommendations have been implemented since the REB was submitted).

Is the use of the Reportable Event Brief form for reporting specific events an interim or long-term solution for events reporting?

The Ministry is planning, during 2009/10, to work with DHBs to develop a user-friendly and possibly web-based tool for events reporting. If implemented, a web-based tool would avoid the need to use forms for reporting on events.

Is it mandatory for DHBs to comply with the new requirements for serious and sentinel events reporting?

The requirement to report, and definitions of what to report on, will eventually be legislated in the Health and Disability Services (Safety) Act 2001 and its associated regulations. This will make events reporting mandatory.

In the interim, the directive from the Minister of Health that there be annual public reporting of events, requires DHBs to provide event information to a central source.

Will only DHBs be required to comply with the new expectations for reporting events?

During 2009/10, the Ministry will work with other health providers (such as disability-related service and aged care providers) to involve them in the policy and systems design for events reporting, and to gain their agreement to report serious and sentinel events in the same way as DHBs.

When will the draft policy be finalised and will DHBs have an opportunity to influence the policy design?

The draft policy for managing healthcare incidents can be found at www.moh.govt.nz/moh.nsf/indexmh/improvingquality-reportableevents-resources.

During 2009/10, the Ministry will work with DHBs and other health providers to finalise the draft National Policy for the Management of Healthcare Incidents, including the definitions and taxonomy for the purposes of events reporting. The policy should be finalised by April 2010.

How will the data about reportable events be used by the Ministry of Health?

The Ministry will not be involved in the DHBs’ investigations of specific cases. The Ministry will use the data to:

prepare an annual report of reportable event statistics, which is released by the Minister of Health
provide the Minister of Health and health-related select committees with data, as required
take a coordinated national approach to the monitoring, analysis, and reporting of trends in incidents
share with the health sector the lessons learned in managing incidents, mitigating their consequences, and reducing the risk of future events.

Does reporting an event compromise my right to privacy?

No. The information submitted to the central repository will be anonymised. Information that could identify the specific patient or staff member(s) involved is NOT to be passed on to the central repository.

In less populated areas, it is the responsibility of the DHB to ensure that the information reported does not create the potential for the patient to be identified. Furthermore, there is a requirement that DHBs notify the person or families involved in reportable event case prior to the publication of the annual report, even though they will not be specifically identified.

The annual report will contain the only information released to the public, this will not include any DHB-specific information relating to incidents.

Who is the contact in the Ministry of Health about events reporting?

The contact details for the Ministry’s centralised reporting function are:

Administrator: Kathryn Baker
Email: reportable_events@moh.govt.nz
DDI: (04) 816 2439
Fax: (04) 816 4318

What events involving Mental Health do I continue to report to the Director of Mental Health?

As of 1 July 2009, the majority of events involving mental health will be reported using a Reportable Event Brief to the national reporting function. The following events are to continue being reported only to the Director of Mental Health:

notifications in accordance with section 132 of the Act;
any adverse events involving special patients; and
any adverse events that are likely to draw media attention.

Will I receive an acknowledgement of receipt when submitting a Reportable Event Brief?

Yes. The Reportable Events Administrator will contact you via email upon receipt of the report. This email will contain an event reference number which is unique to that report. This event reference number should be noted with your records and quoted when updating your Reportable Event Brief within 70 days of the event's occurrence.

Website feedback
We welcome your feedback on this page.
Page last updated: 6 August 2009