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N Z Med J. 2010 May 14;123(1314):18-30.

Opportunities to learn from medical incidents: a review of published reports from the Health and Disability Commissioner.

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  • 1Bay of Plenty District Health Board, Tauranga Hospital, Tauranga, New Zealand.



To analyse recent published information about the Health and Disability Commissioner's investigations in the context of The New Zealand Medical Council's Domains of Competence and investigate possible relationships.


Retrospective review of 100 recent Health and Disability Commissioner (HDC) investigations published online (all cases reviewed regardless of the Commissioner's 'verdict'), involving at least one medical practitioner. Breaches and issues raised were categorised according to the Domains of Competence set by the Medical Council of New Zealand.


The most common area of competence identified in the HDC investigations was that of Medical Expert, in 92.9% of cases. The second was Communication, identified in 48.7% of cases. Many cases included more than one Domain of Competence, with an average of 1.8 domains per investigation. Further characteristics of the cases were examined and a number of medical practitioner, patient, setting and timing statistics are also presented.


This study finds medical expertise and communication skills to be the key areas of a medical practitioner's role that public complaints address. Beyond this, the limited data available through the Commissioner's published reports make it difficult to draw conclusions which might assist with the improvement of medical practice in New Zealand. We therefore conclude that the data available is useful only at a case-by-case level. More extensive use of published information about incidents involving medical practitioners will have to await changes to provide for the systematic reporting of a much higher proportion of incident investigations. Given New Zealand's current environment for dealing with medical complaints, this may require changes beyond the area of consumer complaint investigations considered here.

[PubMed - indexed for MEDLINE]
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