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Face masks, vision, and risk of falls
An article from the British Medical Journal with useful tips for mitigating the risk of falls in older people, while wearing a face mask.
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Learning from health care harm: System safety report
This system safety report combines harm data and insights from multiple agencies to identify recurring themes, system learning opportunities and priorities for reducing avoidable harm across New Zealand's health system.
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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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Bula Sautu – A window on quality 2021: Pacific health in the year of COVID-19
The latest in our ongoing Window on Quality series focuses on health for Pacific peoples, from maternity to end of life, using a life-course approach, and includes expert perspectives on how the health system is performing for Pacific peoples.
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Appropriate medication use in aged residential care: Optimising the use of antibiotics, antipsychotics and fentanyl
This report focuses on optimising the use of particular medicines in aged residential care. It was originally published in May 2020 and updated in June 2022.
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Learning from adverse events report 2018/19
This is the annual learning from adverse events report for 2018/19, 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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Learning from adverse events report 2017–18
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.
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Highlights in 2024/25
Some of the work highlighted in our Annual report
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Embedding te Tiriti in capability programme design and delivery
Commission staff members Jane Cullen and Dr Te Raina Gunn presented at GP22 on embedding te Tiriti in capability design and delivery. See the slides from their presentation here.
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Te Whatu Ora - Nelson Marlborough case study: Trauma at the top of the South
The transition from hospital to home can be challenging for patients who have experienced major trauma. The team at Te Whatu Ora – Nelson Marlborough identified that discharge information is often complex and confusing for patients.