New Zealand has an excellent health care system which provides safe and efficient care to the vast majority of people using its services. However, adverse events can still occur due to failures in the system. At the centre of every adverse event there is a consumer and their whānau. We have a responsibility to these people to review, learn, implement effective changes to the system and share learnings across health and disability services.

The Commission’s Adverse Events Learning Programme guides and supports New Zealand’s health and disability services with a nationally consistent approach to reporting, review and learning from adverse events and near misses.

To contact the Adverse Events Learning Programme team email


Helen McKernan talks about her mother’s death, following a hospital medication error.  
Helen's mother was given the wrong medication for four days because of a chart mix up and inadequate checking.

Adverse Events Learning Programme team

  • Dr Iwona Stolarek, Clinical Lead
  • Sarah Upston, Specialist
  • Sandy Blake, Clinical Expert
  • Kiri Milne, Project Manager
  • Kat Lawrie, Administrator

Last updated 29/06/2017