Gordon Campbell | Parliament TV | Parliament Today | Video | Questions Of the Day | Search


Launch of the Sentinel Events Workbook

18 February 2002
Hon Annette King Speech Notes

Tonight’s official launch of the Sentinel Events Workbook is an important step in building a safety culture in the New Zealand health and disability sector.

The Workbook will help providers by providing logical and easy-to-follow advice about what a ‘safety culture’ could mean in their own workplace.

I would be very surprised if there is anyone in this audience who does not believe this is welcome, but I believe tonight’s launch is also important for another reason.

Last Thursday, in opening the Counties Manukau Integrated Care 2002 conference, I discussed the importance of leadership in developing the exciting and innovative concept of integrated care in New Zealand.

Tonight I want to mention leadership again, in another area this time. In terms of developing a safer culture in health in New Zealand, it is absolutely fundamental that we rid ourselves of our fascination with needing to name, blame or shame someone when something goes wrong.

How can we possibly expect to develop a committed and positive health workforce if the workforce believes it will be on trial whenever a mistake occurs?

Mistakes will occur. It is inevitable in a sector as diverse and as complicated and as subject to pressure as the health sector. The important thing should be to learn from mistakes, not to name, blame and shame someone who has perhaps made a genuine error.

But before I say more about that, to return first to the Workbook, it represents a practical response where it is needed and a meaningful way to back up this Government’s commitment to a safety culture.

The Workbook will be an excellent learning prompt for DHBs and for individual workplaces at all levels, nationally and regionally.

It provides a number of common quality improvement tools and charts, and integrates these with methodologies to allow a comprehensive approach to analysing mistakes and errors.

As many here know, the Workbook has resulted from a recommendation to the Director-General of Health from the Sentinel Event Working Party in September 2001. The Working Party recommended development of resources to guide health and disability staff through steps they need to take when investigating mistakes, and how to apply lessons learned to prevent recurrences.

The Workbook is funded by the Ministry of Health and is published by Standards New Zealand. It is to be used in conjunction with the Ministry of Health’s Reportable Events Guidelines.

It is my hope, and the Workbook’s premise, that standard methodologies for investigating sentinel events, the most serious of errors and mistakes, will help replace the fear of being “named, blamed and shamed”.

The Workbook, in fact, recognises that discovering and reporting mistakes, errors and close calls, should not be punished, but encouraged and rewarded.

While the Workbook is designed to assist with investigating rare events, the 1 in 1000 reportable events that is a sentinel event, the principles and suggestions it contains will also be useful for preventing smaller mishaps.

The cultural change we are seeking will only be achieved through the cumulative effect of both small and big changes.

If left unchecked, the fear of being “blamed, named and shamed” will undermine the attempt to achieve a safety culture.

The culture of “blame and shame” leads to mistrust, an inability and unwillingness to discuss and address problems, and an unnecessary use of resources that could be put to more effective use delivering health and disability services.

Deficiencies in processes, rather than the actions of individuals, are the most common reason for errors and mistakes. This is an absolutely crucial starting point if we are to move to a safety culture.

I read the following comment in Issue 49 of The Specialist, the magazine of the Association of Salaried Medical Specialists. “Recruitment and retention require a supportive environment. They are severely threatened by the blame and shame approach … Much of the solution to this rests with politicians and the media. And it would not cost a cent to turn around.”

As I told the ASMS executive last week, I agree, and I will certainly do what I can to provide the environment for this to happen.

The Workbook is also a product of, and illustration of, the need for better collaboration and cooperation in the health sector. Indeed, the Workbook has only been possible because of extensive consultation with the sector, and cooperation within the sector in putting it together. It shows the importance of breaking down professional silos, and recognising that medical staff, quality experts and health managers all have a role to play in fostering a safety culture.

There has been close cooperation between the Ministry and Standards New Zealand in producing the Workbook. Standards New Zealand is having a vital role in promoting several publications laying the groundwork for a safety culture, including the recently launched Health and Disability Safety Standards.

Other changes associated with the Sentinel Working Group are also occurring. A Child and Youth Mortality Review Committee has now been established, and nominations have been called for the National Health Epidemiology and Quality Assurance Advisory Committee. Both committees are based on the premise that greater clinical input in investigating events will help identify solutions and improvements.

The most effective way of realising the goal of minimising mistakes and errors is to have a trusting working culture that allows errors to be investigated and addressed in a thoroughly open manner. The alternative of a closed and untrusting approach is in no one’s best interests, least of all patients.

The cultural change can’t be reached overnight or as the result of just one publication, but this Workbook will help provide the groundwork.

I am very pleased to be here celebrating this launch. I applaud the hard work that has gone into the Workbook and everyone involved in the project can be proud of what has been produced. I will continue to watch developments regarding patient safety with great interest, and will do my bit to provide leadership where that is needed.

Achieving a safety culture in health is not just an issue of interest to experts only. It is a real issue for the thousands of New Zealanders who access health and disability services each year.

Many patients are naturally, and understandably, apprehensive when they need care, but this Workbook will play its part in providing reassurance and reinforcing trust and confidence in our health and disability services. That is something we can all applaud.

© Scoop Media

Parliament Headlines | Politics Headlines | Regional Headlines


Ruataniwha: DOC, Hawke's Bay Council Developer Take Supreme Court Appeal

The Department of Conservation and Hawke's Bay Regional Investment Company (HBRIC) are appealing to the Supreme Court over a conservation land swap which the Court of Appeal halted. More>>


With NZ's Marama Davidson: Women’s Flotilla Leaves Sicily – Heading For Gaza

Women representing 13 countries spanning five continents began their journey yesterday on Zaytouna-Oliva to the shores of Gaza, which has been under blockade since 2007. On board are a Nobel Peace Laureate, three parliamentarians, a decorated US diplomat, journalists, an Olympic athlete, and a physician. A list of the women with their background can be found here. More>>

Gordon Campbell: On The Key Style Of Crisis Management

At Monday’s post Cabinet press conference Key was in his finest wide- eyed “Problem? What problem?” mode. No, there wasn’t really a problem that top MPI officials had been at odds with each other over the meaning of the fisheries policy and how that policy should be pursued... More>>


Mt Roskill: Greens Will Not Stand In Likely Post-Goff By-Election

“The Green Party’s priority is changing the Government in 2017, and as part of that we’ve decided that we won’t stand a candidate in the probable Mt Roskill by-election... This decision shows the Memorandum of Understanding between Labour and the Green Party is working." More>>


Wellington: Predator Free Capital Plan

Wellington City Council (WCC), the Greater Wellington Regional Council (GWRC) and NEXT Foundation, today announced a joint collaboration to make Wellington the first Predator Free capital city in the world. More>>


Gordon Campbell: On Judith Collins’ Efforts At Self Correction

Thousands of prisoners currently in prison may be entitled to an earlier release than expected – and compensation – because Corrections has incorrectly calculated their term of imprisonment. Unless of course, the government buries its mistakes by changing the law and retro-actively getting itself off the hook… More>>


More Justice & Corrections

Sector Opposes Bill: Local Government Bill Timeframe Extended

The Minister of Local Government Peseta Sam Lotu-Iiga has asked the Select Committee to extend the report back date for the Local Government Act 2002 Amendment Bill (No 2). More>>


Get More From Scoop



Search Scoop  
Powered by Vodafone
NZ independent news