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Review tool & report and supporting user guide

The developed review tool and user guide are designed to help:

  • understand why HCW COVID-19 infections occurred
  • focus on the system and work environment rather than the individual 
  • review controls that were in place to prevent or minimise the outcome of a HCW COVID-19 infection
  • identify opportunities to strengthen risk controls to prevent HCW COVID-19 infections and/or minimise the outcome in the future. 

The tool guides health services through an evidence-based incident review methodology (AcciMap) to identify contributing factors to then develop actions to reduce the likelihood of future HCW COVID-19 infections and improve staff and patient safety. Additionally, the user guide sequentially leads and informs the review team through the process, explaining and defining each of the sections from the initial incident summary, what happened, why it happened, and how improvements can be made.

Download the HCW COVID-19 review tool user guide

Download the HCW COVID-19 review tool and report

Insights from health services

This report was produced with WorkSafe Victoria, and analyses the top 10 contributing factors for healthcare workers in hospitals and residential aged care facilities, and preventive measures that have been introduced. 

Download Learning from healthcare worker COVID-19 infections

The aim of this report is to learn from this to better protect healthcare workers during a pandemic.
In 2020, 4170 healthcare workers contracted coronavirus (COVID-19). From July 2020, services voluntarily provided their investigations into healthcare worker transmissions, including:

  • 223 cases in nine metropolitan public and private hospitals
  • 74 cases in private residential aged care facilities.

This summary report describes insights from health services who experienced COVID-19 outbreaks among frontline staff. It shares the lessons learned, best practice examples and opportunities for statewide improvement.

Download Summary of insights shared by health services

These insights are based on interviews with 12 infection control and occupational health and safety staff from six Victorian health services. Interviews were conducted with WorkSafe Victoria in October and November 2020, following the second wave of the pandemic in Victoria. The interviews built upon analysis of data health services provided about common contributing factors in healthcare worker infections.

The findings are sorted into eight themes:

  1. The virus and testing
  2. Safely accommodating COVID-19 patients
  3. Patient and staff movement
  4. Caring for patients
  5. Personal protective equipment
  6. Staff wellbeing
  7. Managing health service staffing
  8. Managing infection prevention measures
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