The nature of assessment and treatment of patients, involving a wide range of illnesses and/or injuries across the lifespan means occasionally, a patient may inadvertently have an adverse event.
Definition: Adverse events are events with negative reactions or results that are unintended, unexpected or unplanned (often referred to as ‘incidents’ or ‘reportable events’). In practice adverse events are most often understood as events which result in harm to a consumer (Health Quality & Safety Commission New Zealand. Te ako mai i te pōautinitini Adverse Events).
The fundamental role of an adverse events reporting system is to enhance patient safety by learning from these events. When a patient experiences an adverse event while receiving an assessment and/or treatment the Physiotherapy Board (Board) expects that the patient’s physiotherapist will advise the patient (or the patient’s family or whānau) of the facts of the adverse event. The Board endorses the following principles, which underpin this standard:
- open communication
- patient participation
- culturally appropriate practice review
- system changes
- reporting must be safe, ensuring there is no fear of retribution to the patient or physiotherapist.
The Board believes that the open disclosure and reporting of any adverse event will benefit the health and safety of the public and strengthen the physiotherapist-patient relationship.
The physiotherapist has an obligation to mitigate, as far as possible, the effects of any adverse event.
It is important that all adverse events and any unexpected effects from physiotherapy are managed, reported and evaluated using relevant mechanisms and in accordance with local policies and procedures.
The National Adverse Events Reporting Policy 2017 details the obligations of all health and disability service providers. This includes how to classify adverse events using the Severity Assessment Code (SAC) rating tool. There are also Adverse event reporting templates within this policy document.
New Zealand Law
Physiotherapists should make patients aware, through the informed consent process that all assessments and treatments carry some risks, and they may inadvertently experience an adverse event (See Informed consent standard).
2. Open disclosure
Open disclosure contributes to a successful physiotherapy-patient relationship by ensuring the trust is not compromised. It is not about attributing blame.
(See Aotearoa New Zealand Code of Ethics and Professional Conduct, 6.6)
2.1. Disclosure should be in a timely manner.
2.2. Involve and seek advice from experienced colleagues and, if applicable, your employer.
2.3. The disclosure should include:
- what happened
- how it happened
- the consequences for the patient, including continuity of care
- what will be done to avoid similar circumstances in the future?
3. Reporting an adverse event
The nature of the harm and any subsequent action, including disclosure to the patient must be documented in the patient record.
3.1. Any adverse event must be disclosed and recorded appropriately (see Physiotherapy health record standard)
3.2. Appropriate action should be undertaken in accordance with local policies and procedures.
3.3. The classification must be determined using SAC (Appendix A, National Adverse Events Reporting Policy 2017).
3.4. Any SAC 1 or 2 events must be reported to the Health Quality and Safety Commission as per the National Adverse Events Reporting Policy 2017.
3.5. If the patient was referred by another health practitioner, that practitioner must be informed.
4. Following an adverse event
Following an adverse event, a systems analysis should be undertaken to help prevent reoccurrence of a similar incident.
The analysis and prevention measures undertaken must be recorded, including the efficacy of any resultant changes.
Physiotherapists should seek support from senior colleagues (Aotearoa New Zealand Code of Ethics and Professional Conduct, 6.6).
Physiotherapy New Zealand (PNZ) encourages documentation of adverse events via an electronic form on the member website. The Physiotherapy Acupuncture New Zealand (PAANZ) Special Interest Group recommends all PAANZ members record adverse events using the PNZ system. The data is collated yearly and a report published on the member website.
Learning from adverse events reports. Health Quality & Safety Commission New Zealand
The National Adverse Events Reporting Policy 2017. Health Quality & Safety Commission New Zealand