System accountability Tā te pūnaha kawenga
Templates to support review processes.
Health and disability service providers will be accountable for ensuring the systems they implement recognise the various degrees and types of harm (physical, psychological, cultural or spiritual) and meet national expectations for reporting, healing, learning and improving.
Recognising and reporting harm
This review tool is intended to be used by those writing learning reports following events of harm, to inform the development of the written report.
This guide summarises the new principles and processes required to enact the 2023 policy and has a frequently asked questions section to help answer questions you may have.
These tools are a visual guide to the process of recognising, reviewing and reporting harm using Severity Assessment Code (SAC) criteria.
These example guides explain the process of rating and reviewing consumer harm that occurs within an organisation. Please note, the guides are not exhaustive lists.
Eight sector-specific SAC example guides are currently in development with the sector using a co-design process and will be available in quarters 3 and 4 of 2023/24.
The Always Report and Review list is a subset of events that hospital specialist services and health and disability providers should report and review, irrespective of whether the consumer experienced harm.
This guide aims to enable health providers to review harm by applying the learning review method.
Use this template to complete a review using the learning review method.
These optional templates are available to assist with reviews of pressure injuries or falls.
The Systems Engineering Initiative for Patient Safety (SEIPS) is one example of sociotechnical human factors model that assists people to illustrate the following three components:
- the work system, processes and outcomes
- key characteristics or factors of each
- how the components affect one another
SEIPS can be used by anyone as a general systems analysis and problem-solving tool.
Use this template to prepare terms of reference for a review.
This assessment tool supports health and disability service providers to implement the policy when reviewing health care harm. The tool is designed as a maturity assessment checklist to evaluate both operational processes and a completed review of harm to see where the gaps are in meeting the criteria within the policy.
Our quarterly dashboard is an interactive tool for exploring a national summary of adverse events data.
Event of harm review tool
This review tool is intended to be used by those writing learning reports following events of harm, to inform the development of the written report.
Access the event of harm review tool.
Submit an event
Follow this link to report harm to Te Tāhū Hauora Health Quality & Safety Commission.
User guide: Healing, learning and improving from harm: National adverse events policy 2023 | Te whakaora, te ako me te whakapai ake i te kino: Te kaupapa here ā-motu mō ngā mahi tūkino 2023
This guide summarises the new principles and processes required to enact the 2023 policy and has a frequently asked questions section to help answer questions you may have.
Severity Assessment Code (SAC) rating and process tool
These tools are a visual guide to the process of recognising, reviewing and reporting harm using Severity Assessment Code (SAC) criteria.
SAC example guides
These example guides explain the process of rating and reviewing consumer harm that occurs within an organisation. Please note, the guides are not exhaustive lists.
Eight sector-specific SAC example guides are currently in development with the sector using a co-design process and will be available in quarters 3 and 4 of 2023/24.
View all the SAC examples here
Always Report and Review list
The Always Report and Review list is a subset of events that hospital specialist services and health and disability providers should report and review, irrespective of whether the consumer experienced harm.
Read the always report and review list 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.
Read the learning review guide here.
Learning review template
Use this template to complete a review using the learning review method.
View the learning review template.
Falls and pressure injuries templates
These optional templates are available to assist with reviews of pressure injuries or falls.
View the pressure injury review template.
View the falls review template.
Systems Engineering Initiative for Patient Safety Human Factors tool
The Systems Engineering Initiative for Patient Safety (SEIPS) is one example of sociotechnical human factors model that assists people to illustrate the following three components:
- the work system, processes and outcomes
- key characteristics or factors of each
- how the components affect one another
SEIPS can be used by anyone as a general systems analysis and problem-solving tool.
Terms of reference template
Use this template to prepare terms of reference for a review.
View the learning from harms terms of reference template.
Implementation assessment tool
This assessment tool supports health and disability service providers to implement the policy when reviewing health care harm. The tool is designed as a maturity assessment checklist to evaluate both operational processes and a completed review of harm to see where the gaps are in meeting the criteria within the policy.
View the implementation assessment tool.
Adverse events national quarterly dashboard
Our quarterly dashboard is an interactive tool for exploring a national summary of adverse events data.
Other links
An overview to help clinicians better understand the various methodologies available when reviewing an event.
Information on the Privacy Act 2020 and the privacy principles.
Overview of mental health and addiction adverse event review methods, types and approaches
An overview to help clinicians better understand the various methodologies available when reviewing an event.
WorkSafe’s approach to the health care and social assistance sector
This position sets out Worksafe's regulatory approach to the health care and social assistance sector. It also outlines their expectations of PCBUs (persons conducting a business or undertaking) in the sector.
View the position statement here.
Privacy legislation and assessments
Information on the Privacy Act 2020 and the privacy principles.
Published: 20 Jun 2023
Modified: 20 Jun 2024
