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Adverse events exception reporting 2020/21: Thematic analysis involving always report and review eventsThis thematic analysis reviewed all wrong consumer and wrong site always review and report events, reported to Te Tāhū Hauora Health Quality & Safety Commission by district health boards between 1 July 2017 and 30 June 2021.
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Adverse events exception reporting 2020/21: Thematic analysis involving Māori and Pacific peoplesThis paper presents a thematic analysis of severity assessment code (SAC)-1 and 2 adverse events involving Māori and Pacific peoples reported to Te Tāhū Hauora Health Quality & Safety Commission from 1 July 2017 to 30 June 2021.
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Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gapThis paper (Social Science and Medicine 73 (2011) 217-225) examines the challenges of investigating clinical incidents through the use of Root Cause Analysis.
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Patient story: Matthew GunterMatthew was 16 years old when he developed appendicitis. His mum, Heather, took him to the local emergency department and he had surgery that night to remove his appendix.
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Representing the consumer voice in an adverse event reviewSheila from Te Pukaea (Whanganui DHB's consumer council) talks about her experience as an independent consumer representative on adverse event review panels.
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Always Report and Review list 2021–22The Always Report and Review list is a subset of adverse events that health providers should report and review in the same way as SAC 1 and 2 rated events, irrespective of whether or not there was harm to the consumer.
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National summary of adverse events reported to the Health Quality & Safety Commission 1 July 2019 to 30 June 2020A national summary of adverse events reported to the Health Quality & Safety Commission 1 July 2019 to 30 June 2020.
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Maternity early warning system (MEWS) short-stay maternity vital signs chart (MVSC)The national maternity early warning system (MEWS) short-stay maternity vital signs chart (MVSC) supports the recognition of and response to deteriorating women in short-stay/assessment areas, such as women’s assessment units...
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Open4Results – June 2019Our six-monthly report on the harm prevented, and money saved, in areas the Health Quality & Safety Commission focuses on or raises awareness about.
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Open4Results – December 2018Our six-monthly report on the harm prevented, and money saved, in areas the Health Quality & Safety Commission focuses on or raises awareness about.