Resource library Whare rauemi

This is the annual learning from adverse events report for 2017–18, published by the Health Quality & Safety Commission. The report covers adverse events reported by New Zealand's 20 district health boards (DHBs) and other providers.

The purpose of the London Protocol is to ensure a comprehensive and thoughtful investigation and analysis of a clinical incident.

National Adverse Events policy 2017

This presentation given by global trigger tool clinical lead, Gillian Robb, provides an update on the use of trigger tools in New Zealand.

The Global Trigger Tool (GTT) is a methodology developed by the Institute for Healthcare Improvement to identify patient harm that occurs in health care organisations.

In this year three in 10,000 admissions to DHBs involved a potentially preventable serious or sentinel event. Of these 39 percent were a result of a clinical mismanagement problem

Serious and Sentinel Events in New Zealand Hospitals 2007–2008.

Commentary on serious and sentinel events reported by District Health Boards in 2006–2007.

This document provides evidence for the use of checklists, briefings and debriefings, providing an overview of research and studies undertaken in various hospitals.