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Displaying 21 - 30 of 84 results
- Systems Engineering Initiative for Patient Safety Human Factors tool
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Learning from adverse events report 2017–18
This 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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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.
- Learning review template
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Open Book: Acting on X-ray reports (June 2015)
This Open Book describes changes made as a result of X-ray results not being responded to appropriately. The unifying theme for both incidents described is that there was no fail-safe step in the sign-off of results.
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Presentations from learning session one of the Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project
Presentations from learning session one of the Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau | Learning from adverse events and consumer, family and whānau experience project held on 12–13 February 2020.
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E-learning module: Human Factors | Ngā Āhua Tangata
The e-learning module, Human Factors | Ngā Āhua Tangata in health care includes seven videos and is available free to all in health care professionals via the LearnOnline platform.
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Open Book: Different presentations of heparin (February 2015)
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.
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Learning review workshop with Dr Ivan Pupulidy and Prof Crista Vesel
An in-person learning review workshop with the developers of the method, Dr Ivan Pupulidy and Prof Crista Vesel.
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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.