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Learning from adverse events report 2018/19
This is the annual learning from adverse events report for 2018/19, published by the Health Quality & Safety Commission. The report covers adverse events reported by New Zealand's 20 district health boards (DHBs) and other providers.
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Always report and review list 2018–19
The always report and review list is a subset of adverse events that should be reported and reviewed in the same way as SAC 1 and 2 rated events, irrespective of whether or not there was harm to the consumer/patient.
- A guide to the national adverse events reporting policy 2017
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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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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.
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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.
- Policy implementation assessment tool
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Guide to doing a learning review
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Adverse events exception reporting
These documents summarise adverse event exception reporting for the 2020/21 and 2021/22 financial years.
- Always Report and Review list 2023 –24