Healing, learning and improving from harm Te whakaora, te ako me te whakapai ake i te kino

Healing, learning and improving from harm: National adverse events policy 2023 provides a national framework for health and disability providers to continually improve the quality and safety of services for consumers, whānau and health care workers.

The policy:

• provides a consistent way to understand and improve through reporting, reviewing and learning from all types of harm.
• guides providers reporting to the Health Quality & Safety Commission Te Tāhū Hauora.
• supports using the information gathered from learning reviews, along with quality improvement approaches, to strengthen system safety.

Read the healing, learning and improving from harm policy

Submit a harm (adverse) event to the Commission

If you have any queries about the policy, please email:  harm.event@hqsc.govt.nz. 

Our education programme helps you to put the policy into practice.

The workshops will help you:  

• review health care harm while improving consumer, whānau and health care worker safety 
• understand everyday work that supports healing, learning and improving, in a consistent way 
• create quality improvement actions across health systems to reduce the risk of harm
• understand the essential components of high-quality harm (adverse) event review 
• take part in a simulated harm (adverse) event review.  

Find out more about upcoming workshops 

If you have any queries about the workshops, please email:  learningfromharm@hqsc.govt.nz. 

These resources are useful for applying SAC ratings in harm (adverse) event reporting:

• SAC examples
• SAC rating and process tools

The ARR list is events that hospital specialist services and health and disability providers should report and review, whether or not the consumer experienced harm.

Access the list

The policy is founded on eight principles. These pages describe each principle and provide related resources to support you in applying this framework when reporting, reviewing and learning from harm:

• consumer and whānau participation
• culturally responsive practice
• equity
• open communication
• restorative practice and hohou te rongo
• safe reporting
• system accountability
• system learning.

The user guide helps organisations to put into practice the processes and principles detailed in the policy.

Read the user guide

This video discusses the importance of relationships with consumers and whānau in reducing harm, and healing, learning and improving when harm does occur.

The harm (adverse) events submission portal allows providers to submit an event to the Commission.

Submit an event