Search results
Displaying 41 - 50 of 85 results
-
Open Book: Epidural medicines through intravenous lines (September 2015)
This report aims to alert providers to the key findings of a recent review, with an update on new engineering standards being introduced worldwide to prevent Luer misconnections.
-
Guide to doing a learning review
- Always Report and Review list 2023 –24
-
Reporting and reviewing adverse events involving consumers of mental health and addiction services
This purpose of this document is to provide guidance to the MHA sector and clarify its obligations under the national policy. Note: This is an interim document pending the update of the National Adverse Events Reporting Policy in 2022.
-
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.
-
Maternity early warning system (MEWS) short-stay maternity vital signs chart (MVSC)
The national maternity early warning system (MEWS) short-stay maternity vital signs chart (MVSC) supports the recognition of and response to deteriorating women in short-stay/assessment areas, such as women’s assessment units...
-
Adverse events exception reporting 2020/21: Thematic analysis involving Māori and Pacific peoples
This paper presents a thematic analysis of severity assessment code (SAC)-1 and 2 adverse events involving Māori and Pacific peoples reported to Te Tāhū Hauora Health Quality & Safety Commission from 1 July 2017 to 30 June 2021.
-
Adverse events exception reporting
These documents summarise adverse event exception reporting for the 2020/21 and 2021/22 financial years.
-
Open Book: Alert for prescribing error – dabigatran and enoxaparin (July 2017)
This report alerts providers to adverse event cases reported to the Commission’s Adverse Events Learning Programme.
-
Open Book: Interventions or procedures performed outside operating theatre settings – wrong procedure/wrong site/wrong person (Oct 2017)
This report alerts providers to key findings and actions following review of preventable events relating to interventional procedures. The aim is to learn from the events to prevent future similar events.