This Standard is secondary legislation made by the Physiotherapy Board under section 118(i) of the Health Practitioners Competence Assurance Act 2003.
Introduction
The nature of physiotherapy assessment and management of kiritaki, across a wide range of presentations and throughout the lifespan, means that adverse events may occasionally occur.
In practice, adverse events are most commonly understood as events which result in harm to kiritaki.
This standard should be read alongside Healing, learning and improving from harm: National Adverse Events Policy 2023 | Te whakaora, te ako me te whakapai ake i te kino: Te kaupapa here ā‑motu mō ngā mahi tūkino 2023.
Events in which a physiotherapist experiences harm are outside the scope of this standard (covered by other legislation).
Relationship with Physiotherapy Standards Framework
This standard should be read in conjunction with Informed consent standard, Physiotherapy health records standard, Aotearoa New Zealand Physiotherapy Code of Ethics and Professional Conduct (2026) and the other components of the Physiotherapy Standards Framework.
Purpose of the standard
The purpose of the Adverse event standard is to protect the health and safety of the public by:
- ensuring open disclosure, appropriate reporting and analysis of adverse events
- ensuring that learning takes place and the risk of reoccurrence of similar events can be reduced.
Defined terms
Terms and wording used within this standard that are linked are defined in the defined terms.
Adverse event
An incident or situation in which kiritaki experience an unplanned, unexpected, or unintended adverse outcome.
Carer
Someone who assists/supports kiritaki.
Cultural safety
In the context of physiotherapy in Aotearoa New Zealand, cultural safety requires health professionals to examine themselves and the potential impact of their own identities and culture on their practice. Culturally safe health professionals acknowledge and address their own power, privilege, biases, attitudes, assumptions, stereotypes, prejudices, and characteristics that may affect the quality of care provided. Cultural safety requires a critical consciousness where health professionals engage in ongoing self‐reflection and hold themselves accountable for culturally safe practice, as defined by patients and their communities, and as measured through progress towards achieving health equity. Culturally safe health professionals influence healthcare to reduce bias and achieve equity within the workforce and working environment. Cultural safety benefits all patients and communities.
(Curtis et al., 2025, p. 2).
Cultural competence
In the context of physiotherapy in Aotearoa New Zealand, cultural competency refers to a set of knowledge about culture(s), along with the associated skills and behaviours that health professionals require, to deliver high‐quality health care and achieve equitable health outcomes for all groups.
(Curtis et al., 2025, p. 2)
Cultural responsiveness
To weave cultural safety and cultural competence together (sharing the relationship between kiritaki and physiotherapist and working together with respect).
Harm
An outcome that negatively affects the health or quality of life of an individual. Harm may or may not relate to risks discussed during the informed consent process.
Kiritaki
Patient, client, consumer.
Support person
Trusted individuals such as a whānau, family member, friend, or advocate who accompany kiritaki to consultations to provide emotional support, help them understand information, and ensure their rights are respected.
Tangata whenua
Māori people of a particular locality, or as a whole the original inhabitants of Aotearoa New Zealand.
Tauiwi
Non‐Māori, European, Pākehā
Whānau
This is generally described as a collective of people connected through a common ancestor (whakapapa) or as the result of a common purpose (kaupapa).
Whakapapa and kaupapa are not mutually exclusive. Whakapapa whānau will regularly pursue kaupapa or goals. Whereas kaupapa whānau may or may not have whakapapa connections. Whakapapa whānau and kaupapa whānau are social constructs and as such can be located along a continuum depending on the function and intent.
Terminology
Must: is where the statement sets a minimum standard that all physiotherapists are obliged to achieve.
Should: is where a statement marked as ‘should’ recognises that in some contexts and situations the physiotherapist requires a degree of flexibility in their response. Guidance is offered by the ‘should’ statement, but it is up to the individual physiotherapist to decide, and be able to justify, by using their professional judgement and/or seeking advice from experienced colleagues.
Te Tiriti o Waitangi
The Board te Poari acknowledges Te Tiriti o Waitangi as a founding document of Aotearoa New Zealand and respects Māori as tangata whenua. The standard integrates the articles and overarching principles of Te Tiriti o Waitangi with the aim to improve health equity between Māori and Tauiwi.
Te Tiriti o Waitangi was signed in 1840 between the British Crown and many indigenous Māori leaders and is one of Aotearoa New Zealand’s founding documents. Te Tiriti o Waitangi is te reo Māori version of this agreement, and the Treaty of Waitangi is the English language version. There are notable differences observed between the English and te reo Māori texts.
To practise effectively in Aotearoa New Zealand, a physiotherapist needs to understand the relevance of and be able to apply the Tiriti o Waitangi principles, while promoting equitable opportunity for positive health outcomes within the context of Māori health models, including whānau (family health), tinana (physical health), hinengaro (mental) and wairua (spiritual health).
New Zealand Law
Physiotherapists must be familiar with the law governing this area of practice including, but not limited to, the:
Code of Health and Disability Services Consumers’ Rights 1996
Health Practitioners Competence Assurance Act 2003
Open disclosure
A physiotherapist must:
- Disclose an adverse event to kiritaki (or, where appropriate, their family, whānau, support person or carer) as soon as practicable, using a culturally responsive approach.
Commentary: Open disclosure often supports trust in kiritaki-physiotherapist relationships and is not about attributing blame.
Disclosure should include:
- what happened
- how it happened
- why it happened
- the consequences for kiritaki, including continuity of care
- actions taken, or planned, to reduce the risk of it happening again
(See Aotearoa New Zealand Code of Ethics and Professional Conduct (2026), 6.7)
Reporting an adverse event
A physiotherapist must:
- Document the adverse event and details of any disclosure within the health records (see Physiotherapy health record standard).
- Comply with all requirements for reporting the adverse event to the Health Quality and Safety Commission Te Tāhū Hauora.
A physiotherapist should:
- Inform the referrer of kiritaki of the adverse event, where applicable.
Commentary: Seek support from experienced colleagues (see Aotearoa New Zealand Code of Ethics and Professional Conduct (2026), 6.7).
Analysis of an adverse event
A physiotherapist must:
- Undertake or participate in an analysis of the event.
Commentary: Undertaking an analysis after an adverse event can help physiotherapists to learn from the event and reduce the risk of a reoccurrence of a similar event.
- Record the analysis and any steps taken.
Commentary: See Aotearoa New Zealand Code of Ethics and Professional Conduct (2026), 6.7
Related resources
From Physiotherapy Standards Framework
Aotearoa New Zealand Code of Ethics and Professional Conduct (2026), 6.7
Informed consent standard
Physiotherapy health records standard
Physiotherapy practice thresholds in Australia & Aotearoa New Zealand (2024)
From other sources
Healing, learning and improving from harm. Health Quality & Safety Commission
Health and Disability Commissioner Guidance on Open Disclosure Policies
Physiotherapy New Zealand – Patient Adverse Event Reporting
SAC rating and process tool. Health Quality & Safety Commission
References
Curtis, E., Loring, B., Jones, R., Tipene‐Leach, D., Walker, C., Paine, S.-J., & Reid, P. (2025). Refining the definitions of cultural safety, cultural competency and Indigenous health: Lessons from Aotearoa New Zealand. International Journal For Equity in Health, 24 Article 130.