Do New Zealand’s existing systems for reporting medical harm work effectively?

New Zealand's medical harm reporting systems face several critical issues that undermine their effectiveness in ensuring patient safety. These systems struggle with consistency, transparency, and inter-agency coordination, impacting the ability to learn from adverse events and prevent future harm.

NZ's harm reporting is marked by inconsistencies across various health agencies, including the HQSC, ACC, and the MOH. Reports often vary in content and categorisation, making it difficult to track trends and assess the true extent of medical harm. Further, adverse event reporting is not mandatory, and there is no centralised system to capture data uniformly across the healthcare sector.

There is a significant lack of transparency about how harm data is used and shared among health agencies. There is also no comprehensive mechanism for tracking harm caused by individual practitioners, which makes it difficult to identify repeat offenders and ensure accountability. The lack of a mandatory, centralised harm reporting system contributes to this opacity, leaving patients in the dark about the safety measures being taken to protect them.

Despite ongoing efforts by the HQSC to encourage a learning culture, the existing reporting frameworks, such as the Severity Assessment Code (SAC) and Risk of Harm (ROH) notifications, are insufficient for fostering significant safety improvements. The SAC system is not robust enough to capture all incidents accurately, and the process for making ROH notifications remains flawed. Furthermore, health professionals often depend on patients and ACC to report harm rather than proactively identifying risks themselves.

Cases such as the harm caused by surgical mesh and foetal anticonvulsant syndrome illustrate the deep rooted flaws in NZ’s harm reporting systems. The ACC has streamlined its reporting process in recent years, but inconsistencies in data reporting between ACC, Medsafe, and HQSC remain significant. The issues are further exacerbated by the limited oversight in the private health sector, where regulatory gaps make it challenging to enforce safety standards consistently.

The 2023 National Adverse Events Policy aims to standardise harm reporting across health organisations, but it remains a voluntary system, which limits its impact. To address these systemic challenges, experts have also recommended establishing a National Patient Safety Commissioner in NZ. This role would focus on integrating harm data, enforcing transparency, and driving system-wide improvements in patient safety.

While NZ has made strides in promoting a culture of safety, significant changes are needed to enhance the effectiveness of its harm reporting systems. Strengthening data integration, increasing transparency, and introducing a centralised oversight body could help ensure that the health system learns from past incidents and better protects patients from avoidable harm.