Displaying 501 - 510 of 648 results
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Open Book: Red reflex assessment in newborns (June 2016)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.
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Open Book: Incorrect assembly of surgical equipment (June 2016)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.
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National Adverse Events policy 2017National Adverse Events policy 2017
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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.