Resource library

This first trigger tool Open Book report focuses on cases from a hospital setting. Trigger tools are also used in primary care. The aim of this report is to encourage reflective learning using harm triggers identified in one organisation.

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 simila

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).

This report alerts providers to key findings and actions following review of delayed recognition of lack of red reflex in a newborn. The findings from this case extend across care settings, specialties and national guidance.

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.

National Adverse Events policy 2017

This 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.

The likelihood and consequences tables are used by district health boards (DHBs) to assist with the classification of incidents by DHB quality and risk managers.