Health Quality & Safety Commission | Publications & Resources

27 total results, showing page 1 of 3

All Publications & Resources

• Root Cause Analysis For Clinical Incidents
  

  Root Cause Analysis For Clinical Incidents

  Publication in Reportable Events 22nd Feb 2013 22 attachments

  This document provides advice on how to manage the Root Cause Analysis (RCA) process for Severity Assessment Code 1 and 2 incidents to assist RCA Teams.

• Reporting and reviewing adverse events involving users of mental health services - December 2012

  Reporting and reviewing adverse events involving users of mental health services - December 2012

  Publication in Reportable Events 20th Dec 2012 1 attachment

  Recommendations to follow for local review of adverse incidents involving users of mental health services.

• 1. Making our hospitals safer - Serious and Sentinel Events 2011/2012
  

  1. Making our hospitals safer - Serious and Sentinel Events 2011/2012

  Publication in Reportable Events 19th Nov 2012 Featured 3 attachments

  This is the Commission's third report setting out the serious and sentinel events that New Zealand's 20 District Health Boards have reported in the previous year, and the sixth report overall.

• Severity Assessment Criteria tables

  Severity Assessment Criteria tables

  Resource in Reportable Events 1st Oct 2012 2 attachments

  The Likelihood and Consequences tables are used by District Health Boards (DHBs) to assist with the classification of incidents by DHB Quality and Risk Managers.

• Helen McKernan discusses mother's hospital treatment

  Helen McKernan discusses mother's hospital treatment

  Resource in Reportable Events 4th Sep 2012

  Helen McKernan talks about her mother’s death, following a hospital medication error.

• Systems Analysis of Clinical Incidents: The London Protocol

  Systems Analysis of Clinical Incidents: The London Protocol

  Link in Reportable Events 23rd Jul 2012 1 attachment

  The purpose of the London Protocol is to ensure a comprehensive and thoughtful investigation and analysis of a clinical incident.

• Questions & Answers about applying the Reportable Events Policy

  Questions & Answers about applying the Reportable Events Policy

  Resource in Reportable Events 30th Mar 2012 1 attachment

  These questions and answers are in relation to common queries about applying the reportable events policy, and are aimed primarily at a clinical/technical audience, rather than the general public.

• 2. Making our hospitals safer - Serious and Sentinel Events 2010/2011

  2. Making our hospitals safer - Serious and Sentinel Events 2010/2011

  Publication in Reportable Events 20th Feb 2012 4 attachments

  This report details serious and sentinel events in District Health Boards in the year 2010 to 2011.

• Guidance on open disclosure

  Guidance on open disclosure

  Publication in Reportable Events 20th Feb 2012 1 attachment

  The attached document provides guidance on open disclosure for reportable events.

• Reportable Event Brief Form 2012

  Reportable Event Brief Form 2012

  Resource in Reportable Events 15th Feb 2012 2 attachments

  This is the form used for reporting adverse events.