Reporting harm must be accompanied by analysis that leads to system improvement. We encourage providers to use the ‘learning review’ method when reviewing harm. This method is designed for complex adaptive systems like health and disability taking a systems approach.
Why use a systems approach
When developing learning opportunities and actions a systems approach:
- considers all levels of the system
- incorporates a human factors approach
- considers the people, tools, tasks, internal and external environments, providers and their culture
- is ethical, inclusive and respectful
- improves sustainable learning and change.
Learning and education
Learning from harm education programme information
This programme teaches how to review health care harm, understand work that supports healing and create system learning opporunities that can become improvement actions to reduce the risk of future harm.
Learn more about the programme
Learning review module
This module is a refresher for review facilitators who have completed the learning from harm education programme. It can also provide governance groups with an overview of the process.
View the learning review module
Understanding co-design module
This course explores the six stages of a co-design process and how to engage consumers, whānau, staff and other stakeholders to design and provide health services that better meet the needs of people.
Micro-credentialling links
In these micro-credential courses developed with Te Ngāpara Centre for Restorative Practice, you will learn about the theory, values, and principles of restorative practices within the health system context and a Tiriti o Waitangi framework. You will consider how restorative practice and hohou te rongo (peace-making from a Māori world view) might be applied in your own health setting.
Learning module: Human Factors | Ngā Āhua Tangata
Human Factors is the scientific discipline concerned with understanding interactions between people and other parts of the systems they work within. It applies theory, principles, data and methods to design improvements that optimise both human wellbeing and system performance.
Explore the human factors learning module
Thematic analyses
We combine information from a range of providers to see if the harm from individual events is repeating across the health system. These thematic analyses of harm (adverse) event reports help us spot patterns and share information that can be used to strengthen the whole system.
View the thematic analyses page
Shared learning tool
The shared learning tool can be used by health providers to capture and share lessons learned following events of harm.
Dr Ivan Pupulidy: Moving gracefully from compliance to learning
Dr Pupulidy shares activities and leadership actions that practitioners used to change the way an organisation responded to accidents and incidents. He also shares some of the research behind the changes that took place.
Harm (adverse) events exception reporting
The recording, analysis and reporting of harm (adverse) events is now included in the quality alerts to give a more comprehensive picture of harm.
Learn more about harm (adverse) events exception reporting
Report: Ngā Taero a Kupe: Whānau Māori experiences of in-hospital adverse events
This report is based on the information gathered during a research project of whānau Māori experiences of in-hospital adverse events.
NHS patient safety learning response toolkit
The Patient Safety Incident Response Framework (PSIRF) from the UK promotes a range of system-based approaches for learning from patient safety incidents. These tools incorporate the well-established SEIPS framework (Systems Engineering Initiative for Patient Safety).
Published: 20 Jun 2023
Modified: 26 Jan 2026
