Putanga me ngā rauemiPublications & resources

Open Book: Dispensing errors: Learning from the national primary care patient experience survey (Jan 2019)

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.

Presentations from Delivering resilient health care: A workshop with Professor Erik Hollnagel

18 Dec 2018, Adverse Events

Presentations from the Health Quality & Safety Commission's workshop with Professor Erik Hollnagel: Delivering resilient health care.

Learning from adverse events report 2017–18

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.

Template: Quality check for adverse event analysis (SAC 1 and 2)

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.

Always report and review list 2018–19

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.

Guide to partnering with whānau following an adverse event

2 May 2018, Adverse Events

Eight-step guide to partnering with whānau following an adverse event.

Learning from adverse events report 2016–17

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.

Open Book: Interventions or procedures performed outside operating theatre settings – wrong procedure/wrong site/wrong person (Oct 2017)

26 Oct 2017, Adverse Events

This report alerts providers to key findings and actions following review of preventable events relating to interventional procedures.

Representing the consumer voice in an adverse event review

10 Oct 2017, Adverse Events

Sheila from Te Pukaea (Whanganui DHB's consumer council) talks about her experience

Adverse events shared learning tool

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.

Open Book: Alert for prescribing error – dabigatran and enoxaparin (July 2017)

18 Jul 2017, Adverse Events

This report alerts providers to adverse event cases reported to the Commission’s Adverse Events Learning Programme.

Review of the national reportable events policy 2012: Summary of stakeholder feedback

30 Jun 2017, Adverse Events

A guide to the national adverse events reporting policy 2017

30 Jun 2017, Adverse Events

Adverse event brief: Part A

30 Jun 2017, Adverse Events

Adverse event brief: Part B

30 Jun 2017, Adverse Events

Severity Assessment Code (SAC) examples

30 Jun 2017, Adverse Events

National adverse events reporting policy 2017

30 Jun 2017, Adverse Events

Severity Assessment Code (SAC) rating and triage tool for adverse event reporting

30 Jun 2017, Adverse Events

National Adverse Events policy 2017

19 Jun 2017, Adverse Events

National Adverse Events policy 2017

Open Book: Lessons learnt from reviewing patient falls (March 2017)

29 Mar 2017, Adverse Events

Falls are one of the most common causes of injury to patients in hospital. This Open Book was written in collaboration with the Health Quality & Safety Commission’s Reducing Harm from Falls programme. It summarises four falls events, review findings and r