HFA Consults Clinicians About Learning From Serious Events
The Health Funding Authority is consulting with health and disability service providers on a robust process for
reporting and analysing serious events in hospitals.
HFA quality auditor, Gillian Bohm, says the aim of the consultation is to develop a process where organisations and
healthcare professionals learn from the mistakes of others and improve their own systems.
“Investigations of serious events in New Zealand have shown that similar problems keep recurring. The health sector
needs a standard process of investigating serious events and disseminating the results of the investigation within the
“In New Zealand, as in other countries, the health sector is behind other sectors, such as aviation and engineering, in
improving safety for people. In those sectors, equipment and systems are designed assuming that human failure will
occur, whereas in health, too often there is a culture of blaming the individual.
“The health sector needs a standardised process that focuses on systems and learning, rather than individuals and
blame,” Ms Bohm says.
The standard process proposed in the consultation document focuses on establishing the “root causes” of events.
“The focus of the process is to find things that, if eliminated or corrected, would have prevented a serious event from
occurring,” Ms Bohm says.
The consultation document discusses such areas as what events should be reported and to whom, how to learn from events,
and what other countries are doing.
The consultation document has been sent to hospital CEOs, medical and nursing colleges, consumer groups and other
stakeholders. Additional copies of the consultation document can be obtained by calling 0800 ENQUIRE (0800 367 8473) or
by visiting the HFA’s webiste: www.hfa.govt.nz. The consultation closes on 20 October 2000.
Enquiries: (04) 495 4335 or (04) 495 4417