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Displaying 71 - 80 of 85 results
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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.
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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.
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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.
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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.
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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.
- A guide to the national adverse events reporting policy 2017
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Masterclass with Professor Erik Hollnagel
In this masterclass Erik will present on a modern view of safety, Safety II and resilience engineering, and building resilience in healthcare.
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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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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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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.