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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.

Adverse events learning programme team

  • Dr David Hughes, clinical lead
  • Caroline Tilah, senior manager, patient safety and capability
  • Glen Mitchell, specialist, adverse events
  • Jane Lester, programme coordinator
  • Matt Coulson, programme coordinator
  • Corry Joseph, project manager

To contact the adverse events learning programme team email

Last updated: 16th December, 2021