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Displaying 31 - 40 of 55 results
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Open4Results – June 2019
Our six-monthly report on the harm prevented, and money saved, in areas the Health Quality & Safety Commission focuses on or raises awareness about.
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Presentations and videos from the co-design workshop on learning from adverse events
Presentations from the first co-design workshop for 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.
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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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Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap
This paper (Social Science and Medicine 73 (2011) 217-225) examines the challenges of investigating clinical incidents through the use of Root Cause Analysis.
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National Adverse Events policy 2017
National Adverse Events policy 2017
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Severity assessment code (SAC) examples
Examples of the severity assessment codes for adverse event reporting are available below.
- Learning from harms terms of reference template
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Serious and Sentinel Events in New Zealand Hospitals 2006–2007
Commentary on serious and sentinel events reported by District Health Boards in 2006–2007.
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Serious and Sentinel Events in New Zealand Hospitals 2008–2009
In this year three in 10,000 admissions to DHBs involved a potentially preventable serious or sentinel event. Of these 39 percent were a result of a clinical mismanagement problem
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Residential Disability Support Services Severity Assessment Code (SAC) examples 2025
This list is for guidance only. All events should be rated on actual outcome for the consumer.