PUBLICATION: 17 Jan 2019, Adverse Events
This report alerts providers to key medication-related findings from the national primary care patient experience survey, and includes some recommendations for improvement.
NEWS: 8 Nov 2017
The latest issue of the Health Quality & Safety Commission's e-digest for the period of 18 October – 8 November 2017 is now available online.
PUBLICATION: 26 Oct 2017, Adverse Events
This report alerts providers to key findings and actions following review of preventable events relating to interventional procedures.
NEWS: 25 Jul 2017
The latest issue of the Health Quality & Safety Commission's e-digest for the period of 12–25 July 2017 is now available online.
PUBLICATION: 18 Jul 2017, Adverse Events
This report alerts providers to adverse event cases reported to the Commission’s Adverse Events Learning Programme.
NEWS: 3 Apr 2017, Reducing Harm from Falls
An update on April Falls, a national initiative to promote falls reduction in health care settings.
PUBLICATION: 29 Mar 2017, Adverse Events
Falls are one of the most common causes of injury to patients in hospital. This Open Book was written in collaboration with the Health Quality & Safety Commission’s Reducing Harm from Falls programme. It summarises four falls events, review findings and r
PUBLICATION: 30 Jun 2016, Adverse Events
This report alerts providers to key findings and actions following review of two incidents in different organisations where surgical equipment was assembled incorrectly resulting in patient harm in the operating theatre.
PUBLICATION: 16 Jun 2016, Adverse Events
This report alerts providers to key findings and actions following review of delayed recognition of lack of red reflex in a newborn.
NEWS: 24 May 2016
Issue 50 of the Health Quality & Safety Commission's e-update is now available online.
PUBLICATION: 20 May 2016, Adverse Events
This report alerts providers to key findings and actions following review of an outbreak of a multi-drug resistant organism (MDRO) which affected five patients. The aim is to learn from the changes implemented after the event to prevent future similar eve
PUBLICATION: 20 May 2016, Adverse Events
This report alerts providers to key findings and actions following review of a serious healthcare associated infection related to the insertion and management of a peripheral intravenous cannula (PIVC).
PUBLICATION: 28 Apr 2016, Adverse Events
Issue 6 of Let's Talk Triggers, the e-newsletter from the Commission's Trigger Tools programme.
PUBLICATION: 12 Apr 2016, Adverse Events
This first trigger tool Open Book report focuses on cases from a hospital setting. The aim of this report is to encourage reflective learning using harm triggers identified in one organisation.
NEWS: 29 Feb 2016
Issue 48 of the Health Quality & Safety Commission's e-update is now available online.
PUBLICATION: 25 Feb 2016, Adverse Events
This report alerts providers to key findings from three similar recent incident reviews at different hospitals.
PUBLICATION: 25 Feb 2016, Adverse Events
This report alerts providers to the potential danger of using unfamiliar acronyms in communications between services.
PUBLICATION: 17 Dec 2015, Adverse Events
This report alerts providers to findings from review of cases reported to the Health Quality & Safety Commission involving retained vaginal swabs after childbirth.
PUBLICATION: 16 Dec 2015, Adverse Events
This report alerts providers to the key findings of a review, and changes to systems relating to loan instruments for specialised procedures.
MEDIA RELEASE: 4 Dec 2015, Adverse Events
Learning from things that go wrong in health care is a focus of this year’s adverse events report.
PUBLICATION: 30 Sep 2015, Adverse Events
This report aims to alert providers to the key findings of a recent review, with an update on new engineering standards being introduced worldwide to prevent Luer misconnections.
PUBLICATION: 31 Aug 2015, Adverse Events
This Open Book report alerts providers to key findings of a recent review into safe discharge processes for norovirus.
PUBLICATION: 12 Aug 2015, Adverse Events
This Open Book report alerts providers to key findings of a recent review into central venous catheters (CVCs) for hospitalised patients.
NEWS: 14 Jul 2015, Health Quality & Safety Commission
Issue 43 of the Health Quality & Safety Commission's e-update is now available online.
PUBLICATION: 30 Jun 2015, Adverse Events
This Open Book describes changes made as a result of X-ray results not being responded to appropriately.