Tā te pūnaha ako
System learning
Learning from harm education
Reporting must be accompanied by meaningful analysis that leads to system improvement. Te Tāhū Hauora prefers providers use the ‘learning review’ method when reviewing harm because it is specifically designed for complex adaptive systems such as health and takes a systems approach.
A systems approach when developing learning opportunities and actions considers all levels of the system. Incorporating a human factors approach reflects the people, their tools, the tasks, the internal and external environments, the providers and their culture.
A commitment to a systems approach that is ethical, inclusive and respectful of everyone involved in or affected by harm from a product, process or system will improve sustainable learning and change.
Education opportunities
Our Learning from harm education programme teaches participants how to review health care harm, understand work that supports healing and create quality improvement actions to reduce the risk of harm. Learn more about the programme here.
This guide aims to enable health providers to review harm by applying the learning review method.
The learning review online module is designed as a refresher for those review facilitators who have completed the learning from harm education programme or to provide governance groups with an overview of the process. View the module here.
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. View the course here.
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. View these courses here.
Human Factors is the scientific discipline concerned with understanding the 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 this e-learning module here.
Learning from harm education programme information
Our Learning from harm education programme teaches participants how to review health care harm, understand work that supports healing and create quality improvement actions to reduce the risk of harm. Learn more about the programme here.
Guide to doing a learning review | He aratohu arotake ako
This guide aims to enable health providers to review harm by applying the learning review method.
Learning review e-module
The learning review online module is designed as a refresher for those review facilitators who have completed the learning from harm education programme or to provide governance groups with an overview of the process. View the module here.
Understanding co-design e-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. View the course here.
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. View these courses here.
E-learning module: Human Factors | Ngā Āhua Tangata
Human Factors is the scientific discipline concerned with understanding the 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 this e-learning module here.
Shared learning
Thematic analyses of adverse event reports combine information from a range of providers to see if the harm from individual events is being replicated across the system. They allow us to look for similarities across the system and share information that can be used to strengthen the whole system, not just individual components.
The shared learning tool can be used by health providers to capture and share local lessons learned following events of harm.
Open Book reports alert providers to the key findings of adverse event reviews. The reports emphasise the changes implemented to stop the event happening again. We advise providers to consider these Open Book reports and whether the changes made are relevant to their own systems. Explore the Open Book reports here.
This talk explores field initiatives and leadership actions that worked directly with practitioners to change the way an organisation responded to accidents and incidents, and some of the research that underpinned the changes that took place. View this talk here.
Te Tāhū Hauora Health Quality & Safety Commission and the Ministry of Health developed a dashboard of quality alerts to identify emerging quality and safety issues. The recording, analysis and reporting of adverse events is now included with other intelligence in the quality alerts to give a more comprehensive picture of harm. Learn more here.
This report was prepared by Te Tāhū Hauora based on the information gathered during a research project of whānau Māori experiences of in-hospital adverse events.
Thematic analyses page
Thematic analyses of adverse event reports combine information from a range of providers to see if the harm from individual events is being replicated across the system. They allow us to look for similarities across the system and share information that can be used to strengthen the whole system, not just individual components.
View the thematic analyses page here.
Shared learning tool
The shared learning tool can be used by health providers to capture and share local lessons learned following events of harm.
Open Book reports
Open Book reports alert providers to the key findings of adverse event reviews. The reports emphasise the changes implemented to stop the event happening again. We advise providers to consider these Open Book reports and whether the changes made are relevant to their own systems. Explore the Open Book reports here.
Dr Ivan Pupulidy: Moving gracefully from compliance to learning
This talk explores field initiatives and leadership actions that worked directly with practitioners to change the way an organisation responded to accidents and incidents, and some of the research that underpinned the changes that took place. View this talk here.
Learning from adverse events annual reports
Adverse events exception reporting
Te Tāhū Hauora Health Quality & Safety Commission and the Ministry of Health developed a dashboard of quality alerts to identify emerging quality and safety issues. The recording, analysis and reporting of adverse events is now included with other intelligence in the quality alerts to give a more comprehensive picture of harm. Learn more here.
Report: Ngā Taero a Kupe: Whānau Māori experiences of in-hospital adverse events
This report was prepared by Te Tāhū Hauora based on the information gathered during a research project of whānau Māori experiences of in-hospital adverse events.
System safety
Resilient health care is defined as the capacity to adapt to challenges and changes at different system levels, to maintain high-quality care. This recognises the dynamic, independent and inter-dependent relationships that make up the health care system and how these interact to create both high-quality care as well as inevitable risk. We use this understanding to develop new approaches to creating safe, high-quality care in Aotearoa and refer to this as He toki ngao matariki Aotearoa. Learn more about resilient health care here.
The Patient Safety Incident Response Framework (PSIRF) from the UK promotes a range of system-based approaches for learning from patient safety incidents. National tools have been developed that incorporate the well-established SEIPS framework (Systems Engineering Initiative for Patient Safety). View the toolkit here.
He toki ngao matariki Aotearoa (resilient health care)
Resilient health care is defined as the capacity to adapt to challenges and changes at different system levels, to maintain high-quality care. This recognises the dynamic, independent and inter-dependent relationships that make up the health care system and how these interact to create both high-quality care as well as inevitable risk. We use this understanding to develop new approaches to creating safe, high-quality care in Aotearoa and refer to this as He toki ngao matariki Aotearoa. Learn more about resilient health care here.
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. National tools have been developed that incorporate the well-established SEIPS framework (Systems Engineering Initiative for Patient Safety). View the toolkit here.
Last updated: 4th July, 2023
