Patient safety and medicines
Recognising, rating and reporting harm and near misses under the national adverse events policy, and turning reports into learning
Registered health practitioners in New Zealand: doctors, nurses, midwives, dental professionals, pharmacists, paramedics and allied health practitioners, and clinical leaders and quality staff who support incident reporting.
Structured learning and a written reflection to show insight after a complaint, an investigation or a responsible authority inquiry.
Focused learning on a core standard of practice, with a certificate and reflection for your portfolio.
This course teaches registered health practitioners in New Zealand how to recognise, report and learn from harm events and near misses. It works through Te Tāhū Hauora Health Quality & Safety Commission's Healing, learning and improving from harm: National adverse events policy 2023 and its user guide from the point of view of the person who has to notice the event, write the report and take part in what follows: the four types of harm, the Severity Assessment Code (SAC), the Always Report and Review list, Part A and Part B reporting to the Commission, and the move from root cause analysis to learning reviews.
The course suits any practitioner registered under the HPCA Act 2003, including doctors, nurses, midwives, dental professionals, pharmacists, paramedics, psychologists and physiotherapists, whether they work in hospitals, primary care, community pharmacy, aged residential care, ambulance services or private practice. It also covers the reporting routes that sit outside your organisation's incident system: deaths reportable to the coroner, adverse reactions and device problems reported to Medsafe, notifiable privacy breaches, WorkSafe notifiable events, and notifications a responsible authority receives under sections 34 and 45 of the HPCA Act.
Reporting is where learning from harm starts, and it is also where practitioners most often hesitate: unsure whether an event counts, worried about blame, or writing a report that helps nobody. HDC opinions and Tribunal decisions show that what a practitioner did after something went wrong is often examined as closely as the event itself. The course shows how to report promptly, factually and without blame, how the system is meant to protect safe reporting, and how to use an event you were involved in as evidence of insight and learning.
10 sections · 29 lessons · 3 hours (estimated) · 20-question final assessment
Final assessment
20scenario-based questions
Certificate of completion
A certificate of completion for your learning portfolio.
The course includes a structured reflective account template: guided prompts to record what you learned, how you will apply it and how the change will show in your practice. It gives you written evidence of insight after a concern, and a ready record for your CPD portfolio.
Write it in your own words and leave out anything that could identify a patient, a colleague or a case. If you have an open complaint or case, talk to your adviser before reflecting on it in writing.
Yes. You apply the SAC to realistic events, distinguishing a provisional from a final rating and actual from potential harm, and learn which events belong on the Always Report and Review list and what documentation decides whether an exclusion applies.
One that is prompt, factual, objective and free of blame. The course shows what belongs in the report and what belongs in the clinical record, how to describe physical, psychological, cultural and spiritual harm, and how to avoid opinions and speculation that help no one learn.
The course covers reporting to the coroner, Medsafe or CARM, the Privacy Commissioner, WorkSafe and a responsible authority, and explains the Commission's two-part (A and B) reporting, learning reviews, reviewing clusters of SAC 3 and 4 events, and feeding back to the people who reported.
The course explains the safe reporting principle, how organisations separate system learning from performance management, and where the protections of the HPCA Act do and do not reach. It does not promise protections the law does not give, and shows how to write accurately and fairly with that in mind.
Yes. It adapts reporting to general practice, community pharmacy, dental practice and aged residential care as well as hospitals. It is independent of HQSC and every authority, takes about 3 hours (estimated) and costs NZ$139; you finish with a 20-question test, which leads to the certificate and a reflective piece about how you report.
Every legal and regulatory point comes from primary sources: the HPCA Act 2003, the responsible authorities' standards and the Code of Health and Disability Services Consumers' Rights. Anything we cannot confirm is left out.
Lessons, scenarios and assessment questions are written by us for each edition separately, then checked for accuracy, teaching quality and fair assessment before publication.
When a code, standard or law changes, the affected courses are reviewed and updated. Reported errors in legal or regulatory facts are corrected first.
Honest communication when care goes wrong: HDC open disclosure guidance, the HQSC adverse events policy, ACC treatment injury and culturally safe apology.
Run or contribute to a learning review: terms of reference, review conversations, network of influences maps, sensemaking and actions that change systems.
Speaking up at the bedside, notifying concerns about colleagues under the HPCA Act and making protected disclosures under the 2022 Act.
