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Displaying 31 - 40 of 85 results
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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.
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Adverse events increase reflects improved reporting systems
The latest Learning from adverse events report shows health providers in New Zealand are continuing to develop and improve their systems for reporting, reviewing and learning from adverse events.
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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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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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Healthcare-associated infection Severity Assessment Code (SAC) examples 2022–23
This list is for guidance only. All events should be rated on actual outcome for the consumer.
- 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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National summary of adverse events reported to the Health Quality & Safety Commission 1 July 2019 to 30 June 2020
A national summary of adverse events reported to the Health Quality & Safety Commission 1 July 2019 to 30 June 2020.
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New e-learning resource available – Human Factors | Ngā Āhua Tangata in health care
The Health Quality & Safety Commission (the Commission) today released a new e-learning module on Human Factors | Ngā Āhua Tangata in health care.
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Pono consumer story: Nicola Peeperkoorn
Nicola Peeperkoorn explores her family’s experience of the mental health and addiction event review process.
- Learning review template