Mō mātou
Our mahi reflects the Commission’s role as an agent of influence for system learning and change. Also, this work must acknowledge the specific context of health care in Aotearoa, incorporating te ao Māori and building on the World Health Organization’s global patient safety action plan.
Meet the systems safety team
Together we support the health sector and provide expert system safety advice by drawing on the team’s collective knowledge, current evidence and experience in safety and quality.
Caroline Tilah is the Senior Manager, System Safety at Te Tāhū Hauora Health Quality & Safety Commission. Before this she was the executive director operations for the quality improvement and patient safety directorate at Capital & Coast District Health Board (DHB). Caroline is a registered nurse with a postgraduate qualification in occupational health and has completed the Institute for Healthcare Improvement’s quality improvement advisor training. She has held several quality and clinical roles, and her passion is working in partnership to improve care.
Dr Carl Horsley is the Clinical Lead for System Safety at Te Tāhū Hauora. He is a dual-trained intensivist currently working in Middlemore Hospital, Auckland. He has a research interest in the use of simulation to build system resilience, the sociology of safety and the intersection of te ao Māori and modern safety science.
Carl recently completed his MSc in Human Factors and System Safety at Lund University, Sweden, with a thesis examining the way in which the current safety norm has been formed and stabilised. He is also an active member of the Resilient Healthcare Network, a collaboration of safety scientists, researchers and clinicians exploring the implications of resilience engineering in health care. Carl is particularly interested in how to embed these ideas in everyday practice and has authored several book chapters on aspects of this work.
Dr Leona Dann is the Specialist, System Safety at Te Tāhū Hauora Health Quality & Safety Commission. Leona is a registered nurse and a midwife with a Master of Midwifery, a doctorate in health science and a postgraduate certificate in ergonomics/human factors. She was a lead maternity care midwife and has also worked in various midwifery leadership positions in DHBs and nationally. Her areas of interest include human factors, learning through understanding the lived experience, the overlap between systems thinking and mātauranga Māori, and restorative responses to health care harm.
Rebekah Mitchell is an advisor in the System Safety team supporting the mahi relating to harm events and system safety. Initially working in the medico-legal space, she then re-trained as a registered nurse and has worked primarily in Emergency and Critical Care. Alongside her clinical practice, she has also held research and quality improvement roles before becoming a Quality and Risk Manager for Acute and Critical Care Services. Rebekah’s areas of interest include harm events and how we respond to these with a restorative practice approach, and she is particularly interested in growing a community of practice around the learning review methodology.
Karen Gibson is the System Safety Strategy and the National Quality Forum Project Manager. With an MBA specialising in project management, she brings experience across diverse project environments, spanning government, humanitarian emergency relief and development, and the telecommunications industry. Most recently, she was a project and quality advisor at a Primary Health Organisation.
Caroline Tilah
Caroline Tilah is the Senior Manager, System Safety at Te Tāhū Hauora Health Quality & Safety Commission. Before this she was the executive director operations for the quality improvement and patient safety directorate at Capital & Coast District Health Board (DHB). Caroline is a registered nurse with a postgraduate qualification in occupational health and has completed the Institute for Healthcare Improvement’s quality improvement advisor training. She has held several quality and clinical roles, and her passion is working in partnership to improve care.
Dr Carl Horsley
Dr Carl Horsley is the Clinical Lead for System Safety at Te Tāhū Hauora. He is a dual-trained intensivist currently working in Middlemore Hospital, Auckland. He has a research interest in the use of simulation to build system resilience, the sociology of safety and the intersection of te ao Māori and modern safety science.
Carl recently completed his MSc in Human Factors and System Safety at Lund University, Sweden, with a thesis examining the way in which the current safety norm has been formed and stabilised. He is also an active member of the Resilient Healthcare Network, a collaboration of safety scientists, researchers and clinicians exploring the implications of resilience engineering in health care. Carl is particularly interested in how to embed these ideas in everyday practice and has authored several book chapters on aspects of this work.
Dr Leona Dann
Dr Leona Dann is the Specialist, System Safety at Te Tāhū Hauora Health Quality & Safety Commission. Leona is a registered nurse and a midwife with a Master of Midwifery, a doctorate in health science and a postgraduate certificate in ergonomics/human factors. She was a lead maternity care midwife and has also worked in various midwifery leadership positions in DHBs and nationally. Her areas of interest include human factors, learning through understanding the lived experience, the overlap between systems thinking and mātauranga Māori, and restorative responses to health care harm.
Rebekah Mitchell
Rebekah Mitchell is an advisor in the System Safety team supporting the mahi relating to harm events and system safety. Initially working in the medico-legal space, she then re-trained as a registered nurse and has worked primarily in Emergency and Critical Care. Alongside her clinical practice, she has also held research and quality improvement roles before becoming a Quality and Risk Manager for Acute and Critical Care Services. Rebekah’s areas of interest include harm events and how we respond to these with a restorative practice approach, and she is particularly interested in growing a community of practice around the learning review methodology.
Karen Gibson
Karen Gibson is the System Safety Strategy and the National Quality Forum Project Manager. With an MBA specialising in project management, she brings experience across diverse project environments, spanning government, humanitarian emergency relief and development, and the telecommunications industry. Most recently, she was a project and quality advisor at a Primary Health Organisation.
Published: 8 Mar 2022
Modified: 8 Mar 2022
