Patient safety and medicines

Systems Analysis After Adverse Events

How to scope, run, contribute to and learn from a learning review or other systems analysis of harm in New Zealand health care

NZ$139Enrol now What is included

3hours (estimated)
10sections
20final questions
80%pass mark
PDFcertificate

Online and self-paced, on any device
Reflective account template
Knowledge checks in every section
Instant certificate of completion

Written for New ZealandUpdated 5 October 2026

What you will learn

Explain why Te Tāhū Hauora no longer recommends traditional root cause analysis and what the learning review is designed to do differently.
Compare the main review methods used in New Zealand (learning review, London Protocol, concise incident analysis, file or desk review, RCA and RCA², AcciMap and FMEA) and choose a proportionate method for a given event.
Draft terms of reference with a clear central question, scope, boundaries and team, and identify conflicts of interest and cultural expertise needs.
Plan and hold non-judgemental review conversations with consumers, whānau and health care workers that explore what happened and how work was being done.
Build a network of influences map and a narrative that shows how decisions made sense to the people involved at the time.
Use sensemaking focus groups and contributory factor frameworks (London Protocol, SEIPS 2.0, Yorkshire framework, AcciMap) to analyse an event without hindsight bias.
Write findings, learning opportunities and improvement actions that are specific, owned, measurable and designed with the people who do the work.
Build equity, Te Tiriti o Waitangi and culturally responsive practice into every stage of a review.
Distinguish a system learning review from processes that assess individual accountability, including HDC, coronial and responsible authority processes and notifications under the HPCA Act.
Apply systems analysis to an event you were involved in to demonstrate insight and learning for recertification or a regulator.

Who this course is for

Registered health practitioners in New Zealand who lead, facilitate, sit on or contribute to reviews of harm: doctors, nurses, midwives, dental professionals, pharmacists, paramedics and allied health practitioners, plus clinical leaders and quality staff.

Doctors (MCNZ) Nurses (Nursing Council) Midwives (Midwifery Council) Dental professions (Dental Council) Pharmacists (Pharmacy Council) Other HPCA Act professions

After a concern

Structured learning and a written reflection to show insight after a complaint, an investigation or a responsible authority inquiry.

Routine CPD

Focused learning on a core standard of practice, with a certificate and reflection for your portfolio.

About this course

This course teaches the methods New Zealand health providers use to analyse harm once it has been reported: the learning review promoted by Te Tāhū Hauora Health Quality & Safety Commission, the London Protocol that many services still use, concise and desk reviews for smaller events, and supporting tools such as SEIPS, AcciMap and contributory factors frameworks. It follows a review from start to finish: writing terms of reference, choosing facilitators, holding conversations with consumers, whānau and staff, building a network of influences map, running sensemaking focus groups, writing findings and learning opportunities, and designing improvements that change the system rather than reminding people to try harder.

It is written for doctors, nurses, midwives, dental professionals, pharmacists, paramedics and allied health practitioners registered under the Health Practitioners Competence Assurance Act 2003 who are asked to lead, facilitate, sit on or give information to a review, and for practitioners in general practice, community pharmacy, dental practice, aged residential care and private practice who need to run a proportionate review in a small setting. It also shows how to apply systems thinking honestly to an event you were personally involved in.

New Zealand moved away from root cause analysis because traditional reviews had not reduced the frequency or severity of harm. A review that ends in 'staff reminded to follow policy' wastes the consumer's story and the practitioners' time; a review that understands how work was really being done can prevent the next event. HDC opinions, coronial findings and responsible authorities increasingly look at what an organisation and its practitioners learned after harm. This course gives you the skills to make that learning real, culturally safe and equitable.

Course details

Learning time: Approximately 3 hours (estimated learning time including knowledge checks, reflection and assessment)
Standards covered: Healing, learning and improving from harm: National adverse events policy 2023 and user guide; Guide to doing a learning review (He aratohu arotake ako) and learning review template; Overview of mental health and addiction adverse event review methods (2024); London Protocol; SEIPS 2.0; Yorkshire Contributory Factors Framework; AcciMap; Code of Health and Disability Services Consumers' Rights; Health Practitioners Competence Assurance Act 2003 (ss 34 and 45, protected quality assurance activities); Health and Disability Services (Safety) Act 2001 and Ngā Paerewa; Coroners Act 2006
Format: Self-paced, gated lessons with knowledge checks, case studies and reflection
Assessment: 20 scenario-based questions, 80% to pass (16 of 20)
Outcome: Certificate of completion and a written reflection for your CPD record
Alignment: Mapped to the national adverse events policy 2023 and Te Tāhū Hauora review guidance, and to the expectations of the responsible authorities under the HPCA Act 2003 (including the Medical Council, Nursing Council, Midwifery Council, Dental Council, Pharmacy Council and Paramedic Council)

Course curriculum

10 sections · 25 lessons · 3 hours (estimated) · 20-question final assessment

1Systems analysis in Aotearoa: purpose, policy and methods3 lessons
- From "who did it" to "how did it happen"
- Where review sits in the national adverse events policy
- The family of review methods and how to choose
2Setting up a review well3 lessons
- Framing the central question and terms of reference
- Choosing facilitators and the review team
- Preparing people and protecting the process
3Gathering information: conversations, normal work and mapping3 lessons
- Review conversations: what and how, not why
- Understanding normal work and adaptations
- Mapping influences rather than drawing a timeline
4Making sense: focus groups and contributory factor frameworks4 lessons
- Sensemaking focus groups
- The London Protocol and contributory factors
- SEIPS, AcciMap and the Yorkshire framework
- Thinking traps in analysis
5From findings to lasting improvement3 lessons
- Writing findings and learning opportunities
- Designing improvements with the people who do the work
- Action plans, measures and closing the loop
6Equity, culture and reviews across settings3 lessons
- Building equity and Te Tiriti into the analysis
- Reviews across boundaries and in small settings
- Reviews in mental health and addiction services
7Systems thinking, accountability and your own practice3 lessons
- When a systems review meets individual accountability
- How HDC, coroners and responsible authorities view reviews
- Applying systems analysis to your own practice
8Conclusion and key points1 lesson
- Conclusion and key points
9References and further reading1 lesson
- References and further reading
10Your reflective account1 lesson
- Your reflective account

Assessment and certificate

Final assessment

20scenario-based questions

Pass mark 80%: 16 correct out of 20
Knowledge checks in each section as you go
Tests whether you can apply the standards, not recall a page
Not passed yet? Review the sections and retake it

Certificate of completion

A certificate of completion for your learning portfolio.

Your name, the course title and the estimated learning time (record the time you actually spend)
Completion date and a unique certificate ID that can be verified
Ready to download as a PDF as soon as you complete the course

Fitness To Practice

Certificate of Completion

This certifies that

Your Name

has successfully completed

Systems Analysis After Adverse Events

Completed12 Oct 2026

3hours (estimated)

Certificate IDFTS-7Q4K-2M9X

Continuing professional development record — New Zealand

Your reflective account

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.

Questions about this course

Why is the course built around learning reviews rather than root cause analysis?

Te Tāhū Hauora no longer recommends traditional root cause analysis, because the search for a single root cause tends to miss how work is really done. The course explains what the learning review does differently and still covers RCA and RCA² so you can work with services that use them.

Which review methods does the course compare?

The learning review, the London Protocol, concise incident analysis, file or desk review, RCA and RCA², AcciMap and FMEA, with guidance on choosing a proportionate method for a given event and drafting terms of reference with a clear central question, scope and team.

How should I talk to staff and whānau during a review?

The course shows how to plan and hold non-judgemental conversations with consumers, whānau and the staff involved that explore what happened and how work was being done, with cultural expertise built in and Te Tiriti obligations considered from the start.

Is a learning review the same as an investigation into my conduct?

No. The course distinguishes a system learning review from processes that assess individual accountability, including HDC, coronial and responsible authority processes and HPCA Act notifications, and explains why mixing the two damages learning and trust. Both have a place, but they answer different questions.

Who should take the systems analysis course?

Quality and safety staff, clinical leaders who commission or facilitate reviews, and any practitioner asked to contribute to one or wanting to analyse an event they were involved in. HQSC has not endorsed it; it is independent. NZ$139 buys 3 hours (estimated), and passing the end test earns a certificate and a review-focused reflection.

How this course was built

Official sources only

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.

Original, edition by edition

Lessons, scenarios and assessment questions are written by us for each edition separately, then checked for accuracy, teaching quality and fair assessment before publication.

Reviewed when rules change

When a code, standard or law changes, the affected courses are reviewed and updated. Reported errors in legal or regulatory facts are corrected first.

Page updated 5 October 2026

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