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Displaying 51 - 60 of 84 results
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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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Representing the consumer voice in an adverse event review
Sheila from Te Pukaea (Whanganui DHB's consumer council) talks about her experience as an independent consumer representative on adverse event review panels.
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Systems Analysis of Clinical Incidents: The London Protocol
The purpose of the London Protocol is to ensure a comprehensive and thoughtful investigation and analysis of a clinical incident.
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Severity Assessment Criteria tables
The likelihood and consequences tables are used by district health boards (DHBs) to assist with the classification of incidents by DHB quality and risk managers.
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Severity assessment code (SAC) examples
Examples of the severity assessment codes for adverse event reporting are available below.
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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 2007–2008
Serious and Sentinel Events in New Zealand Hospitals 2007–2008.
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Open Book: Accurate patient identification (December 2014)
This report aims to alert providers to the key findings of a recent adverse event review. The emphasis is on the changes implemented by the provider involved to stop the event happening again.
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National Adverse Events policy 2017
National Adverse Events policy 2017
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Adverse events shared learning tool
This tool is for sharing learning from events that are not otherwise reported to the Health Quality & Safety Commission under the National Adverse Events Reporting Policy.