Open Book reports aim to alert providers to the key findings of adverse event reviews. The reports emphasise the changes implemented to stop the event happening again.
We advise providers to consider these Open Book reports, and whether the changes made are relevant to their own systems.
The Health Quality & Safety Commission thanks the provider organisations for their commitment to learning from adverse events, and sharing these cases. If any provider believes they have reviewed an incident with important lessons from which others can learn, please contact us.
The Health and Disability Commissioner and ACC also publish lessons learnt from treatment injury claims and complaint investigations. These can be found at the links below.