Tā te pūnaha kawenga
System accountability
Templates to support review processes.
Health and disability service providers will be accountable for ensuring the systems they implement recognise the various degrees and types of harm (physical, psychological, cultural or spiritual) and meet national expectations for reporting, healing, learning and improving.
Recognising and reporting harm
Use these forms to report harm to Te Tāhū Hauora Health Quality & Safety Commission. Download submission form part A here. Download submission form part B here.
Follow this link to report harm to Te Tāhū Hauora Health Quality & Safety Commission.
This guide summarises the new principles and processes required to enact the 2023 policy and has a frequently asked questions section to help answer questions you may have. View the guide here.
These tools are a visual guide to the process of recognising, reviewing and reporting harm using Severity Assessment Code (SAC) criteria. View the tools here.
The Always Report and Review list is a subset of events that hospital specialist services and health and disability providers should report and review, irrespective of whether the consumer experienced harm. Read the list here.
These example guides explain the process of rating and reviewing consumer harm that occurs within an organisation. Please note, the guides are not exhaustive lists.
Eight sector-specific SAC example guides are currently in development with the sector using a co-design process and will be available in quarters 3 and 4 of 2023/24.
This guide aims to enable health providers to review harm by applying the learning review method. Read the guide here.
Use this template to complete a review using the learning review method.
These optional templates are available to assist with reviews of pressure injuries or falls.
The Systems Engineering Initiative for Patient Safety (SEIPS) is one example of sociotechnical human factors model that assists people to illustrate the following three components:
- the work system, processes and outcomes
- key characteristics or factors of each
- how the components affect one another
SEIPS can be used by anyone as a general systems analysis and problem-solving tool.
Use this template to prepare terms of reference for a review.
This assessment tool supports health and disability service providers to implement the policy when reviewing health care harm. The tool is designed as a maturity assessment checklist to evaluate both operational processes and a completed review of harm to see where the gaps are in meeting the criteria within the policy.
Our quarterly dashboard is an interactive tool for exploring a national summary of adverse events data. View the dashboard here.
Submission forms: Part A and B
Use these forms to report harm to Te Tāhū Hauora Health Quality & Safety Commission. Download submission form part A here. Download submission form part B here.
Submit an event
Follow this link to report harm to Te Tāhū Hauora Health Quality & Safety Commission.
User guide: Healing, learning and improving from harm: National adverse events policy 2023 | Te whakaora, te ako me te whakapai ake i te kino: Te kaupapa here ā-motu mō ngā mahi tūkino 2023
This guide summarises the new principles and processes required to enact the 2023 policy and has a frequently asked questions section to help answer questions you may have. View the guide here.
Severity Assessment Code (SAC) rating and process tool
These tools are a visual guide to the process of recognising, reviewing and reporting harm using Severity Assessment Code (SAC) criteria. View the tools here.
Always Report and Review list 2023 –24
The Always Report and Review list is a subset of events that hospital specialist services and health and disability providers should report and review, irrespective of whether the consumer experienced harm. Read the list here.
SAC example guides
These example guides explain the process of rating and reviewing consumer harm that occurs within an organisation. Please note, the guides are not exhaustive lists.
Eight sector-specific SAC example guides are currently in development with the sector using a co-design process and will be available in quarters 3 and 4 of 2023/24.
Guide to doing a learning review | He aratohu arotake ako
This guide aims to enable health providers to review harm by applying the learning review method. Read the guide here.
Learning review template
Use this template to complete a review using the learning review method.
Falls and pressure injuries templates
These optional templates are available to assist with reviews of pressure injuries or falls.
Systems Engineering Initiative for Patient Safety Human Factors tool
The Systems Engineering Initiative for Patient Safety (SEIPS) is one example of sociotechnical human factors model that assists people to illustrate the following three components:
- the work system, processes and outcomes
- key characteristics or factors of each
- how the components affect one another
SEIPS can be used by anyone as a general systems analysis and problem-solving tool.
Terms of reference template
Use this template to prepare terms of reference for a review.
Implementation assessment tool
This assessment tool supports health and disability service providers to implement the policy when reviewing health care harm. The tool is designed as a maturity assessment checklist to evaluate both operational processes and a completed review of harm to see where the gaps are in meeting the criteria within the policy.
Adverse events national quarterly dashboard
Our quarterly dashboard is an interactive tool for exploring a national summary of adverse events data. View the dashboard here.
Other links
An overview to help clinicians better understand the various methodologies available when reviewing an event. View the overview here.
This position sets out Worksafe's regulatory approach to the health care and social assistance sector. It also outlines their expectations of PCBUs (persons conducting a business or undertaking) in the sector. View the position statement here.
Information on the Privacy Act 2020 and the privacy principles. View this information here.
Overview of mental health and addiction adverse event review methods, types and approaches
An overview to help clinicians better understand the various methodologies available when reviewing an event. View the overview here.
WorkSafe’s approach to the health care and social assistance sector
This position sets out Worksafe's regulatory approach to the health care and social assistance sector. It also outlines their expectations of PCBUs (persons conducting a business or undertaking) in the sector. View the position statement here.
Privacy legislation and assessments
Information on the Privacy Act 2020 and the privacy principles. View this information here.
Published: 20 Jun 2023
Modified: 20 Jun 2024
