The report's release comes as health quality and improvement experts and health professionals focus on patient safety at the Asia Pacific Forum in Auckland this week.
It is the commission's first report to look specifically at mental health reportable events.
Events that occurred at inpatient facilities, while the person was on leave from an inpatient facility and when a person went missing from an inpatient facility were previously included in the annual reporting of serious and sentinel events.
Events that occurred in the community while the person was an outpatient were not reported by the commission last year.
While DHB reporting is voluntary, the commission ``strongly encourages it so the sector can learn from these very sad events'', Dr Wilson said.
Ninety-two percent of mental health and addictions service users access only community services, with the remaining eight percent receiving a mixture of community and inpatient services.
Dr Rees Tapsell, director of clinical services at Waikato DHB and executive clinical director at the Midland Regional Forensic Psychiatric Service, said the report contains valuable information for clinicians.
``We have a highly professional and dedicated health workforce but harm does occur,'' he said.
``Not all of it can be prevented, but some of it can be.
``It's the responsibility of all of us working in health to provide the safest care possible.''
Death by suspected suicide was the most frequently reported serious adverse event reported to the Health Quality & Safety Commission between July 1, 2012 and June 30, this year.
The way suspected suicides are reported has changed from last year, which required the event to have occurred within seven days of a person's contact with a mental health and addictions service.
It has been extended to within 28 days of contact with a service. As a result, more cases of death by suspected suicide are likely to be reported in coming years, the commission said.
The commission and Ministry of Health have already agreed in principle to a two-year mortality review trial to improve knowledge about the factors contributing to suicide, patterns of suicidal behaviour, and for better identification of key points to intervene to prevent suicide.
A small group of experts from different sectors will review the contributing factors and possible intervention points leading to a suicide, with the aim of preventing them in future.
A report of their findings and recommendations will be published at the end of the trial.
Where to get help
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (4pm to 6pm weekdays)
• Whatsup: 0800 942 8787 (noon to midnight)
• The Word
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• CASPER Suicide Prevention
If it is an emergency and you feel like you or someone else is at risk, call 111.
