Adverse patient safety events cause harm to patients and clinicians. Adverse event reviews aim to establish why an event occurred. Using Human factors and Systems thinking to design our healthcare system is critical to reducing unintended harm to consumers and clinicians.
Human behaviour and how it relates to the socio-technical system are critical factors in understanding the systems we create. It’s important to understand the many ways that human behaviour and limitations can contribute to adverse events.
Adverse Patient Safety Events require a particular review process to be followed. This module describes the process from identifying that an adverse event has occurred, through to sharing the review outcomes to promote system-wide learning and improvement.
Fundamentals of the Sentinel Event Process introduces Safer Care Victoria's Sentinel Event Program and describes the Sentinel Event review process.