Common errors in aged residential care settings contributing to statutory complaints: a review of cases investigated by the Health and Disability Commissioner in New Zealand.

AIM: Statutory agencies such as the Health and Disability Commissioner (HDC) of New Zealand and the Australian Aged Care Quality and Safety Commission investigate complaints when significant health and safety breaches are identified in aged residential care (ARC). This study aims to identify the human factors that lead to complaints to the HDC in New Zealand ARC. Complaint analysis can identify areas to prioritise to mitigate future complaints and improve quality of care. METHOD: Yin's multiple-case study design was used to guide the research. Cross-case conclusions were drawn using Braun and Clarke's thematic analysis. Twenty-four HDC complaint cases from 2007 to 2021 were investigated using stratified randomised selection across three large ARC organisations. RESULTS: The analysis showed four themes recurred most frequently in the 24 cases examined: 1) communication flaws; 2) documentation gaps; 3) policy-to-practice inconsistencies; and 4) staffing shortages and skill mix insufficiencies. CONCLUSION: The analysis indicated commonly recurring problems. The investigative system could be more effectively managed by proactively investing in a human factors approach, such as the Systems Engineering Initiative for Patient Safety lens, rather than the current approach, which is more likely to apportion blame to individuals. This shift would mean that organisations could avert many harms by engaging experts to examine their complex system holistically and identify multiple parts of the system that contribute to events that currently come before the HDC.