Te whakamahere tiaki i mua i te wā taumaha

Advance care planning

Advance care planning is the process of thinking about, talking about and planning for future health care and end of life care. This page provides information about advance care planning for consumers and clinicians.
Te āhua o te kaitātaki me ngā mahi ka taea

Leadership and capability

Our quality improvement science education and training courses provide skills to address local improvement challenges, as well as building ability to draw on what is available nationally.
Te whakaratonga pai ake

Improved service delivery

The Commission engages with the sector to improve the delivery of health care services though specific quality improvement programmes.
Taupā me te whawhai i te poke

Infection prevention and control

The Commission’s national Infection prevention and control (IPC) programme aims to improve patient outcomes by reducing the incidence and impact of healthcare associated infections (HAIs) within the New Zealand health and disability sector.
Whakapai i ngā mahi hauora hinengaro waranga hoki

Mental health and addiction quality improvement

The mental health and addiction quality improvement programme is a national initiative working with the DHBs to ensure that people who experience mental health and addiction issues, and their whānau, receive high quality care.
Komiti arotake matenga

Mortality Review Committees

Mortality review committees are statutory committees that review particular deaths, or the deaths of particular people, in order to learn how to best prevent these deaths.
Arotakenga Mātai Whēkau ā-Motu

National Bowel Screening Programme Review

In February 2018 Health Minister Hon. Dr David Clark initiated an independent review of the National Bowel Screening Programme.
Te Hononga Whētuki ā-Motu

National Trauma Network

The Health Quality & Safety Commission is contracted by the Accident Compensation Corporation (ACC) to provide support to the Te Hononga Whētuki ā-Motu | National Trauma Network.
He hoa tiaki

Partners in Care

Our programme’s aim is to ensure consumer and whānau engagement in the planning, delivery, and monitoring of health services and therefore a higher quality and safer health system.
Punaha ahuru

System safety

The way we think about safety in the health sector has changed over recent years. We are increasingly recognising the health care system is a complex system that constantly adapts to change.

Mōhiohio kounga e pā ana ki te hauora

Health Quality Intelligence

This programme establishes baseline measures and indicators which can be used to assess the quality of the health and disability system.
Mapi Hauora Kē

Atlas of Healthcare Variation

The Atlas of Healthcare Variation displays easy-to-use maps, graphs, tables and commentaries that highlight variations by geographic area in the provision and use of specific health services and health outcomes.
Te kounga o te tauwhiro hauora

Window on the quality of health care

Every year the Commission publishes a document we call A window on the quality of Aotearoa New Zealand’s health care. The Window provides a snapshot of the quality of health care in the country.
Ngā tohu kounga, tohu haumaru

Quality & Safety Markers

The latest quality and safety marker (QSM) results are available on the left-hand menu. Click the quarter you would like to view and use the anchors at the top of the page to navigate to the programme of interest.
Papatohu kounga

Quality Dashboards

The dashboard brings together everything the Health Quality & Safety Commission knows about local health systems in one place.
Tono raraunga

Data submission

This page is for submitting data around quality & safety markers and Adverse Events.
Open4Results

Open4Results highlights harm prevented and money saved through the improvements made by health services in areas where the Commission has a focus.
Ngā taupānga

Subscribed apps

A list of apps to view data such as prevention quality indicators and the opioids QSM development dashboard.
He ara aupiki, he ara auheke

Patient experience

Patient experience is a vital but complex area. The Health Quality & Safety Commission conducts two national surveys to enable the collection, measurement and use of patient experience information on a regular basis.
Ngā Tohu Hauora, Kounga me te Haumaru

Health Quality & Safety Indicators

Measuring the quality of health care and communicating the results in a variety of ways and settings is a powerful way to stimulate improvement.
Kōrero kounga

Quality Accounts

Quality accounts require health care providers to give an account for the quality of their services in a similar way to financial accounts showing how an organisation used its money.

Whare rauemi

Resource library
Te Pū rauemi KOWHEORI-19

COVID-19 resource hub

Support for people working in health during the COVID-19 pandemic. Find information about how you can support yourselves and others, including consumers, teams and colleagues which complements and aligns with Ministry of Health resources.
Kia āta kōwhiri

Choosing Wisely

The Choosing Wisely campaign seeks to reduce harm from unnecessary and low-value tests and treatment.

He hoa tiaki

Partners in Care

Our programme’s aim is to ensure consumer and whānau engagement in the planning, delivery, and monitoring of health services and therefore a higher quality and safer health system.
Wāhi whakawhiti kōrero hauora

Consumer health forum Aotearoa

A forum for consumers and whānau to have a voice at every level of the health system.
Ngā tikanga mō ngā whāinga

Draft code of expectations

The Commission is developing and welcoming feedback on a code of expectations which will set how health and disability service providers and organisations will involve and work effectively in partnership with consumers and whānau.
Mōhiohio hei hono ki ngā kiritaki

Info for engaging consumers

Information and resources to help the health sector engage consumers and whānau in their work.
Ngā kōrero me ngā whitiata

Consumer stories & videos

A video collection of consumer stories, in their own words.
Te tohu hononga ā-kiritaki kounga

Consumer engagement quality and safety marker

A framework to measure what successful consumer engagement looks like and how it improves the quality and safety of services.
Ngā hononga hauora rite tahi

Health equity links

Examples of strategies helping address inequities in the New Zealand health sector.
Pitopito kōrero mā ngā kiritaki

Consumer hub news and events

Consumer hub news and events for consumer and whānau.

Home >
Our work >
System safety >
Learning from adverse events

Ako mai i ngā kaupapa kino

Learning from adverse events

We improve consumer and staff safety by supporting organisations to report, review and learn from adverse events that occur in health and disability services. We promote a nationally consistent approach to reporting, reviewing and learning.

Mō mātou

About us

Te Kaupapa Here hei tuku pūrongo mō ngā ‘Aituā ā-Motu’

National Adverse Events Reporting Policy

Te tuku kōrero mai i ngā aituā

Reporting from adverse events

Mātauranga

Education

Ngā putanga, ngā taputapu me ngā rauemi

Publications, tools & resources

Ngā korero ki Adverse Events

Adverse Events news

Ngā pātai ki Adverse Events

Adverse Events events

Pito kōrero hou tonu

Latest news

New film focuses on healing and learning from health care harm
Restorative practice Adverse events

14 Sep 2021

A new film, Pou hihiri, Pou o te aroha | Healing and learning from harm, features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event occurs in health care.
Adverse events reports for quarters 1, 2 and 3 of 2020/21 released
Adverse events

27 May 2021

Each year the Health Quality & Safety Commission collects information about adverse events that occur in hospitals and other health care providers and reports on the findings. This is the data for quarter one, two and three of 2020/2021.
More providers to follow adverse events policy from February 2022
Adverse events

22 Nov 2021

The range of health providers who have to follow the Health Quality & Safety Commission’s National Adverse Event Reporting Policy is broadening from 28 February 2022, when the new Ngā Paerewa Health and Disability Services Standard comes into effect.

Ngā rauemi

Featured resources

Te Kaupapa Here hei tuku pūrongo mō ngā ‘Aituā ā-Motu’

National Adverse Events Reporting Policy

Representing the consumer voice in an adverse event review

National summary of adverse events reported to the Health Quality & Safety Commission 1 July 2019 to 30 June 2020

Latest resources

Pou hihiri, Pou o te aroha | Healing and learning from harm

Open Book: Extravasation injury during surgery

Presentations from Resilient health care – embracing the future online hui

View more

Ngā pānui

Events

Using restorative approaches to heal and learn: Humanising harm

Have you observed or been affected by health care harm? For example, a complaint, adverse event, or conflict?

See all events