The Serious and Adverse Events reports signal that Counties Manukau Health (CM Health) has a healthy reporting culture. It is one which is aimed at identifying preventable adverse events and learning from them. This is so that every best effort is made to try and avoid events such as these occurring again.

As part of CM Health's commitment to providing safer care for the patient, we have this report in place to review serious adverse event that occurs in our organisation.  The purpose of reviewing these is to determine the underlying causes of the event so that improvements can be made to the systems of care to reduce the likelihood of such events occurring again.

Serious adverse events reviews at CM Health are undertaken according to the following principles:

  • Establish the facts: what happened, to whom, where, how and why
  • To look for improvements in the system of care rather than apportion blame to individuals
  • To establish how recurrence may be reduced or eliminated
  • To formulate recommendations and an action plan
  • To provide a report as a record of the review process
  • To provide a means of sharing learning from the incident

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