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Displaying 61 - 70 of 85 results
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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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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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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.
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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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Open Book: Preventing retained items – laparoscopic surgery (January 2015)
This report aims to alert providers to the key findings of two recent reviews, with emphasis on the changes implemented to prevent recurrence.
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Pono consumer story: Anne-Marie Douglas
Anne-Marie Douglas shares her experience of mental health challenges that led to a review process.
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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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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.
- Policy implementation assessment tool
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Patient story: Matthew Gunter
Matthew was 16 years old when he developed appendicitis. His mum, Heather, took him to the local emergency department and he had surgery that night to remove his appendix.