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14 Jul 2021, Adverse Events
This report alerts providers of the risk of hypoxic cardiac arrest during percutaneous tracheostomy. The aim is to learn from the event and establish a standard operating procedure to prevent future similar events.
27 Apr 2021, Adverse Events
This is a video recording of a presentation by Professor Paul Bowie about human factors and maternity systems.
5 Mar 2021, Adverse Events
This Open Book introduces the Learning Review, a process originally developed in the United States Forest Service.
10 Dec 2020, Adverse Events
A national summary of adverse events reported to the Health Quality & Safety Commission 1 July 2019 to 30 June 2020.
10 Jul 2020, Adverse Events
A report based on the information gathered during a research project of whānau Māori experiences of in-hospital adverse events.
16 Mar 2020, Adverse Events
Template for part A of the adverse event brief.
21 Nov 2019, Adverse Events
This is the annual learning from adverse events report for 2018/19, published by the Health Quality & Safety Commission. The report covers adverse events reported by New Zealand's 20 district health boards (DHBs) and other providers.
17 Jan 2019, Adverse Events
This report alerts providers to key medication-related findings from the national primary care patient experience survey, and includes some recommendations for improvement.
18 Dec 2018, Adverse Events
Presentations from the Health Quality & Safety Commission's workshop with Professor Erik Hollnagel: Delivering resilient health care.
7 Dec 2018, Adverse Events
This is the annual learning from adverse events report for 2017–18, published by the Health Quality & Safety Commission. The report covers adverse events reported by New Zealand's 20 district health boards (DHBs) and other providers.
31 May 2018, Adverse Events
Template to help providers critique their own adverse events reviews to improve the quality of review processes and learning from adverse events.
9 May 2018, Adverse Events
The always report and review list is a subset of adverse events that should be reported and reviewed in the same way as SAC 1 and 2 rated events, irrespective of whether or not there was harm to the consumer/patient.
2 May 2018, Adverse Events
Eight-step guide to partnering with whānau following an adverse event.
24 Nov 2017, Adverse Events
This is the annual adverse events report published by the Health Quality & Safety Commission. The report covers adverse events reported by New Zealand's 20 district health boards (DHBs) and other providers.
26 Oct 2017, Adverse Events
This report alerts providers to key findings and actions following review of preventable events relating to interventional procedures.
10 Oct 2017, Adverse Events
Sheila from Te Pukaea (Whanganui DHB's consumer council) talks about her experience
18 Jul 2017, Adverse Events
This tool is for sharing learning from events that are not otherwise reported to the Health Quality & Safety Commission under the National Adverse Events Reporting Policy.
18 Jul 2017, Adverse Events
This report alerts providers to adverse event cases reported to the Commission’s Adverse Events Learning Programme.