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Displaying 31 - 40 of 53 results
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Adverse events exception reporting 2020/21: Thematic analysis involving always report and review events
This 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 peoples
This 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 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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Patient story: Matthew Gunter
Matthew 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 review
Sheila 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 2021–22
The 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 2020
A national summary of adverse events reported to the Health Quality & Safety Commission 1 July 2019 to 30 June 2020.
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The Global Trigger Tool: A review of the evidence
This report reviews the literature associated with the development and use of trigger tools to determine rates of harm in health care settings, with particular attention on the Institute of Healthcare Improvement's Global Trigger Tool.
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Open4Results – June 2019
Our 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 2018
Our six-monthly report on the harm prevented, and money saved, in areas the Health Quality & Safety Commission focuses on or raises awareness about.