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Displaying 11 - 20 of 84 results
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Ngā Taero a Kupe: Whānau Māori experiences of in-hospital adverse events
A report based on the information gathered during a research project of whānau Māori experiences of in-hospital adverse events.
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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.
- Learning from harms terms of reference template
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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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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.
- Review of the national reportable events policy 2012: Summary of stakeholder feedback
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Applications open for next Ako tahi hei whakapai ake i te kounga | Improving together: Advisors programme
Applications for 2022/23 are now open for the Health Quality & Safety Commission’s quality improvement education programme Improving together: Advisors, following a successful pilot in 2021/22.
- Healing, learning and improving from harm: National adverse events policy 2023 | Te whakaora, te ako me te whakapai ake i te kino: Te kaupapa here ā-motu mō ngā mahi tūkino 2023
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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.
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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.