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Displaying 11 - 20 of 85 results
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Learning from harm programme restorative responses workbook
This workbook is an introduction to restorative responses in the context of adverse events. A restorative response is a relational approach that is guided by a need to address harm, meet needs, restore trust, prevent repetition and promote repair.
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Delivering resilient health care - a workshop with Professor Erik Hollnagel
The Health Quality & Safety Commission is hosting another workshop with Professor Erik Hollnagel, this time with a theme of applying the theory of Safety II concepts into practice.
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Open Book: Surgery abandoned due to unavailable instruments (December 2015)
This report alerts providers to the key findings of a recent review and system changes made to prevent the incident happening again. In this case, changes were made to systems relating to loan instruments for specialised procedures.
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The Global Trigger Tool: A review of the evidence
This report reviews the literature associated with the development and use of trigger tools to determine rates of harm in health care settings, with particular attention on the Institute of Healthcare Improvement's Global Trigger Tool.
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Principles for engaging consumers and whānau in mental health and addiction adverse event reviews
This information is provided for mental health and addiction (MHA) services. It is intended to guide adverse event review facilitators on the principles of engaging with consumers and their whānau affected by an adverse event and to complement...
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Toolkit released to help DHBs learn from mental health and addiction sector adverse events
The Health Quality & Safety Commission has released a toolkit for triaging, reviewing and learning from adverse events in mental health and addiction services.
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Learning review workshop with Dr Ivan Pupulidy and Prof Crista Vesel
Te Tāhū Hauora Health Quality & Safety Commission is excited to bring you the opportunity to attend an in-person learning review workshop with the developers of the method, Dr Ivan Pupulidy and Prof Crista Vesel.
- Review of the national reportable events policy 2012: Summary of stakeholder feedback
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Adverse events exception reporting 2020/21: Thematic analysis involving always report and review events
This thematic analysis reviewed all wrong consumer and wrong site always review and report events, reported to Te Tāhū Hauora Health Quality & Safety Commission by district health boards between 1 July 2017 and 30 June 2021.
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Open Book: Retained vaginal swabs following childbirth (December 2015)
This report alerts providers to findings from review of cases reported to the Health Quality & Safety Commission involving retained vaginal swabs after childbirth. It includes a summary of evidence and prevention strategies for providers to consider.