Hei Hei Health Centre Significant Event Management Policy

Date Approved: 7/2/2016

Dates Reviewed: 29/7/2025

Purpose:

To reduce the severity and frequency of significant events by:

• Fostering a safe workplace environment for significant incident manngement and;
• Collect information about significant events and;
• Using information collected to manage events and to prevent or defray future events.

Responsible Staff:

          Implementation: Clinical Director

          Action:                All Staff

          Audit:                 Clinical Director

Training Resources:

N/A

Linked Policies:

Health and Safety Policy

Open Disclosure Policy

Enabling Resources:

Incident Reporting Forms (located under the photocopier).

Health and Safety folder (located in reception in grey shelves)

Incident and Open Disclosure Register (located in Health and Safety folder and in "Shared").

National Adverse Events Reporting Policy 2017

Auditing:

N/A

Policy:

There is significant overlap between this policy and the Health and Safety Policy, which also mandates incident reporting.  Where the Health and Safety Policy is in conflict with this policy the provisions of the Health and Safety Policy and the Health and Safety at Work Act 2015 shall apply.

When things do not go as well as they might, it is important to learn from them so that coutcomes may be improved in the future.

To this end, staff are expected to report all "significant incidents" using the incident report form.

A significant event is:

• As defined in the Health and Safety Policy or;
• An incident where someone came to harm or;
• An incident where someone may have come to harm or;
• Any other incident that might effect the smooth running of the practice.

It is also appropriate to use the reporting system for hypothetical events, where the reporting staff member believes there might be potential for harm, even if the situation that might cause it has not yet arisen.  It is better to report these than not.  

Examples include:

• Any harm that results in an ACC claim.
• Any harm that results in a notification to Worksafe and/or emergency services (severe injury or death).
• Loose flooring resulting in a potential trip hazard.
• A practice procedure leading to potential risk.
• Theft from the practice.
• Missing controlled drugs.

When in doubt, it is best to report incidents - do not assume that someone else has noticed  or will manage the incident. Act at once.  You might be endangering others if you dont report the incident or hazard.

Incident reports should include at least:

• Identity of the reporting person.
• Identity of anyone else affected.
• Date, time and location of the incident
• A detailed descreiption of what (or what nearly) happened.
• Action already taken to prevent recurrence.

An incident form is available at reception and provides an outline of the information required to aid in a structured report of the incident, though staff may also include the same information in any other reasonable format.

Memory fades and with delay, critical information maybe lost. Incident forms should be completed as soon as reasonably practicable, and in any case by the end of the first working day after the day on which the incident came to the notice of the reporting person.

Media Response:

A significant event might attract the attention of journalists and other media personnel.  Staff are not permitted to comment on the event to any outside party.  Any requests for information must be made in writing to the Clinical Director by the requesting party.  

Emergency Services and Worksafe:

A severe event may require the immediate summoning of emergency services including the Fire Brigade, Ambulance and Police.  Staff are to use their own judgement if the event requires emergency services, however, the Clinical Director is to be immediately notified of the incident.  

Some incidents require reporting to Worksafe NZ per the Health and Safety at Work Act 2015. Only the Company Officers are authorised to report a severe incident from the notifiable criteria supplied by Worksafe.  All staff are required to preserve the incident scene unless to render aid to an injured person or make an area safe.  This is a requirement of Worksafe for their investigation if needed. 

In the event of a workplace death the Company Officer is required to immediately inform Worksafe's dedicated number, other staff are not permitted to make the call.  The scene is to be preserved while evidence is gathered for Worksafe or Police investigation.  All operations must cease and appointments rebooked until clearence given by Worksafe.

Adverse Reaction to Medication:

It is the responsibility and judgement of the Health Care Practitioner (HCP) to evaluate if a reported reaction to a medication or vaccine should be classed as an Adverse Event.  A minor reaction such as itching or rash may only need to be added to the "Medical Warnings" tab in the PMS per the Data Standards Policy to prevent future prescribing and administration of vaccines.  

Severe reactions or rare side effects to a medication or vaccine may be reported at HCP's discretion to an appropriate agency such as the Centre for Adverse Reaction Monitoring (CARM) or the local immunisation coordinator.  Inwards corresdondence from higher level providers like the Emergency Department of a suspected reaction should be added to Medical Warnings per the Data Standards Policy.

When a client notifies us of a possible reaction the call needs to be appropriately triaged.  Any threat to life should result in the caller being instructed to call the ambulance.  A lower level reaction should be fit in at the next available appointment or nurse triage space or advised to go to alternative provider if a timely appointment cannot be found or is out of hours.

Ongoing Management and Quality Improvement:

The initial respose to the incident will be co-ordinated by the Clinical Director.

The Clinical Director and Staff Administrator should be involved as soon as possible in managing the response to incidents involving harm, or potential harm to clients or staff respectively.

The Clinical Director shall be resposible for creating a detailed report:

• What happened.
• Why it happened and what lessons have been learned.
• What actions have been taken.
• What action needs to be taken, and by whom.

The back of the incident form has a investigative template available for use.

It is intended that the report should be neutral in tone, reflecting the fact that incidents may happen to anyone despite the best of care.  Names of staff and clients should not be included in the report.  Although this is an internal document, the report should be written in a manner that whould be appropriate to share with the client involved in the incident or another agency.

Where necessary, the Clinical Director may require any member of staff to provide assistance.

The purpose of the report should be to encourage the acceptance of events, and responsibility for their prevention.  Wording should reflect this ethos.

Once the report has been drafted, the reporting staff should be asked to review it and make comments which should be taken into account before the report is finalised.  A period of five working days is permissible for a response although this may be reducesd if the matter is urgent for and for any reason or extended where reasonable.

In the event that there is disagreement between the reporting staff member and the Clinical Director and/or Staff Administrator, the areas of disagreement should be noted in the final report, with both preferred versions being presented.

Once the report has been finalised, action reports should be agreed on with affected staff.  The Clinical Director shall be resposible for ensuring that action points are followed up in an appropriate time frame.

It may be appropriate to circulate the repost of the incident more widely but the Clinical Director should exercise discretion in this, taking into consideration:

• Where or not wider circulation would be usefull for prevention of similar incidents.
• The resultant impact on staff affected by the incident.
• Whether the incident might best be managed at a meeting.
• Whether or not it is sufficient to include the matter in an aggregate report to a meeting

Notification to External Agency:

A serious adverse event may require notifying an agency such as the Health Quality and Safety Commision.  The responsibility of any notification is with the Clinical Director to assess if it needs to be reported and to submit the report.  A report may be required within 15 working days of the incident occuring.

Change Log:

29/7/25

Links in old policy broken. Retyped above in alignment of other policys

Replaced Quality Administrator role as no longer in use

Updated Policy to include Health and Safety at Work Act 2015

Added Media Response and Emergency Services section

Updates to align with current procedure and resources e.g Incident forms and their location.

Added Notification to External Agency

 Previous Version:

2016 Policy- Links broken

We are commited to continuous quality improvement.

The Significant Event Management Policy details how we manage the times when things do not (or might not) go so well.

Significant Event Management Policy from 07/07/2016 (pdf format)

Significant Event Reporting Form (.odt format - downloads ready to edit)