Search results
Displaying 41 - 50 of 84 results
-
Pono consumer story: Nicola Peeperkoorn
Nicola Peeperkoorn explores her family’s experience of the mental health and addiction event review process.
-
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.
-
Always Report and Review list 2021–22
The Always Report and Review list is a subset of adverse events that health providers should report and review in the same way as SAC 1 and 2 rated events, irrespective of whether or not there was harm to the consumer.
-
Open Book: Triage of patient with post-procedure ophthalmic symptoms in the emergency department (April 2015)
This report aims to alert providers to the key findings of a recent review, with emphasis on the changes implemented to prevent recurrence. Providers are advised to consider this report, and whether the changes made are relevant to their own systems.
-
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.
-
Open Book: Preventing retained items – gynaecology surgery (March 2015)
This report aims to alert providers to the key findings of a recent review, with emphasis on the changes implemented to prevent recurrence.
-
Open Book: Safety in MRI scanner (May 2015)
This Open Book illustrates the importance of providers standardising the way they apply well-recognised safety steps.
-
Global trigger tool: Using data for improvement
This presentation given by global trigger tool clinical lead, Gillian Robb, provides an update on the use of trigger tools in New Zealand.
-
Gillian Robb talks about the IHI Global Trigger Tool
The Global Trigger Tool (GTT) is a methodology developed by the Institute for Healthcare Improvement to identify patient harm that occurs in health care organisations.
-
Open Book: Lessons learnt from reviewing patient falls (April 2015)
This edition of Open Book was written in collaboration with the Health Quality & Safety Commission’s Reducing Harm from Falls programme, and sets out a series of practice changes made by providers to prevent patients from being harmed by falling.