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Posted on 13 Apr 2023

Victoria’s health system and broader community can benefit from adverse event reviews to identify and then implement appropriate and effective improvements to make healthcare safer.

Healthcare consumers who have been impacted by serious adverse events are entitled to play a role in internal review processes seeking to understand how harm occurred. This includes the patient who was harmed, their family, carers and/or loved ones. The expectation to include consumers in the process is outlined in the Australian Commission for Safety and Quality in Health Care’s National Standards, Incident Management Guide Incident Management Guide (, Australian Open Disclosure Framework The Australian Open Disclosure Framework | Australian Commission on Safety and Quality in Health Care, and Victoria’s new Statutory Duty of Candour (SDC) legislation.

The active involvement of impacted consumers in the review of adverse events ensures a fuller understanding of contributing factors to an event, which leads to the opportunity for more accurate and robust findings, and better system improvements. Having meaningful involvement in the review process can also help to restore consumer confidence in health services, while failing to involve them can lead to additional psychological harm and the escalation of complaints.

Rachel’s Story is an example of how close engagement between a health service and impacted patients added significant value to the review process, produced meaningful improvements, and restored the relationship between the health service and the consumer.

In partnership with health services and consumers, we have developed a set of resources to maximise the effectiveness of engagement between impacted consumers and health services following adverse events.

Resources for health services

Resources for consumers

•    Next Steps pamphlet – a printable resource for health services to provide to impacted consumers during open disclosure or Statutory Duty of Candour discussions. The pamphlet helps explain the adverse event review process and invites consumer involvement. 
•    What happens after patient harm? – a general consumer factsheet about the robust process health services have in place to investigate instances where harm has occurred, which includes a high-level overview of review processes. 


For more information, please contact the Patient Safety Review Team at

Page last updated: 13 Apr 2023