Adverse event review and response

When patients are unexpectedly harmed or die, a review team comes together to find out what happened, why, and how to prevent it from happening again. We help you learn from these events and near misses.

Statutory duty of candour

From November 2022, public and private hospitals will be required to:

• apologise to any person seriously harmed while receiving care 
• explain what went wrong
• describe what action will be taken and improvements put in place.

These requirements come with legal protections around health service apologies and clinical incident reviews. We are developing resources to help health services prepare for and implement duty of candour. Read more about these changes.

A consistent process for reviewing adverse patient safety events

Our Adverse patient safety events policy outlines individual, health service and SCV responsibilities. Aligning your policy to this will help you prioritise reviews and promote a safe reporting environment. Read more tips on reviewing an adverse patient safety event.

Helping you find review team members

• For external reviewers, our PEER platform will connect you with an independent member for your review team.
• For consumer members, download our guide to working together with consumers to review adverse patient safety events.

Training for healthcare workers and consumers

Just Culture Package for health services

Our Just Culture Package includes training for senior leaders within Victorian health services to facilitate Just Culture Training at their own services.  Following the training, a toolkit is provided with all of the resources required to deliver the training internally. 

We conduct regular training in adverse patient safety event reviews. View our events calendar to find the next available session.

Tools and resources

Factsheets

These factsheets provide an introductory overview on key topics relating to adverse patient safety events. They support health services to identify, report, classify, review and learn from adverse patient safety events. The factsheets are in line with training content, guidelines and policies developed by SCV.

Just Culture

A just culture encourages balanced accountability between organisations and individuals, and applies systems-thinking principles to allow fair and just responses to adverse patient safety events. This factsheet helps you understand how a just culture can help you achieve positive outcomes for consumers and your organisation.

Download the Just culture factsheet

Leadership and safety culture

Safety culture refers to an ongoing organisational commitment to safety by all staff within an organisation. This factsheet outlines the role that organisational leaders play in building, maintaining and promoting the principles of a safety culture within their organisation.

Download the Leadership and safety culture factsheet

Cognitive bias

Understand what cognitive biases are and how they can affect both the reviewers of adverse patient safety events and the people involved in the event that is being reviewed.

Download the Cognitive bias factsheet.

Human factors

‘Human factors’ is the study of the interaction between people and the systems they work in. Human factors also refer to a range of systems factors (e.g. governmental, organisational, environmental) that influence human performance. This factsheet will help you understand how human factors contribute to adverse events and helps you undertake a fair review process.

Download the Human factors factsheet

Interviewing for adverse event reviews

Interviews are a key source of evidence to understand what contributed to adverse patient safety events. This factsheet will help you prepare for interviews and use good interviewing principles to reduce interviewer bias.

Download the Interviewing for adverse event reviews factsheet

Guidance Documents 

This guide provides review teams with some practical tips on how to create, share and store documentation collected as part of Adverse Patient Safety Event Reviews. The information provided in this document is underpinned by the principles of Just Culture.

Download Adverse Patient Safety Event Review management guide

Tools

COVID-19 deaths in hospitals review tool

We have developed a systems-focused rapid tool for the review of COVID-19-related adverse events in healthcare settings. The tool guides reviewers through the basic steps of undertaking an adverse event review to examine what happened, how it happened and why it happened. Find out more and download the tool.