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Adverse events exception reporting
These documents summarise adverse event exception reporting for the 2020/21 and 2021/22 financial years.
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Learning review workshop with Dr Ivan Pupulidy and Prof Crista Vesel
An in-person learning review workshop with the developers of the method, Dr Ivan Pupulidy and Prof Crista Vesel.
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National adverse events reporting policy 2017
This is the annual adverse events report 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.
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Presentations from learning session one of the Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project
Presentations from learning session one of the Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project held on 12–13 February 2020.
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Serious and Sentinel Events in New Zealand Hospitals 2006–2007
Commentary on serious and sentinel events reported by District Health Boards in 2006–2007.
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Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap
This 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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Systems Analysis of Clinical Incidents: The London Protocol
The purpose of the London Protocol is to ensure a comprehensive and thoughtful investigation and analysis of a clinical incident.
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Toolkit released to help DHBs learn from mental health and addiction sector adverse events
The Health Quality & Safety Commission has released a toolkit for triaging, reviewing and learning from adverse events in mental health and addiction services.
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Learning from adverse events annual reports
Annual national summaries of adverse events reported to Te Tāhū Hauora Health Quality & Safety Commission.
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Presentations and videos from the co-design workshop on learning from adverse events
Presentations from the first co-design workshop for Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project.