Resource library

Commentary on serious and sentinel events reported by District Health Boards in 2006–2007.

Serious and Sentinel Events in New Zealand Hospitals 2007–2008.

In this year three in 10,000 admissions to DHBs involved a potentially preventable serious or sentinel event. Of these 39 percent were a result of a clinical mismanagement problem

This presentation given by global trigger tool clinical lead, Gillian Robb, provides an update on the use of trigger tools in New Zealand.

This report aims to alert providers to the key findings of a recent adverse event review. The emphasis is on the changes implemented by the provider involved to stop the event happening again.

This report aims to alert providers to the key findings of two recent reviews, with emphasis on the changes implemented to prevent recurrence.

This report aims to alert providers to the key findings of a recent review, with emphasis on the changes implemented by that provider to prevent recurrence.

This report aims to alert providers to the key findings of a recent review, with emphasis on the changes implemented to prevent recurrence.

This report aims to alert providers to the key findings of a recent review, with emphasis on the changes implemented to prevent recurrence. Providers are advised to consider this report, and whether the changes made are relevant to their own systems.

This edition of Open Book was written in collaboration with the Health Quality & Safety Commission’s Reducing Harm from Falls programme, and sets out a series of practice changes made by providers to prevent patients from being harmed by falling.