Displaying 531 - 540 of 685 results
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Adverse events shared learning toolThis tool is for sharing learning from events that are not otherwise reported to the Health Quality & Safety Commission under the National Adverse Events Reporting Policy.
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Severity Assessment Criteria tablesThe likelihood and consequences tables are used by district health boards (DHBs) to assist with the classification of incidents by DHB quality and risk managers.
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Always report and review list 2018–19The always report and review list is a subset of adverse events that should be reported and reviewed in the same way as SAC 1 and 2 rated events, irrespective of whether or not there was harm to the consumer/patient.
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Learning from adverse events report 2017–18This 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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Open Book: Dispensing errors: Learning from the national primary care patient experience survey (Jan 2019)This report alerts providers to key medication-related findings from the national primary care patient experience survey, and includes some recommendations for improvement.
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Open Book: Learning Review (March 2021)This Open Book introduces the Learning Review, a process originally developed in the United States Forest Service.
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Open Book: Hypoxic cardiac arrest during attempted percutaneous tracheostomyThis report alerts providers of the risk of hypoxic cardiac arrest during percutaneous tracheostomy. The aim is to learn from the event and establish a standard operating procedure to prevent future similar events.
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Open Book: Extravasation injury during surgeryThis Open Book alerts providers to the key findings of a recent review of an incident where a patient suffered an extravasation injury that required skin grafts to repair.