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.

Resources for involving impacted consumers

Healthcare patients and their families/carers who have been impacted by serious adverse patient safety events are entitled to play a role in internal review processes that seek to understand how their harm occurred. 

By involving impacted consumers in adverse event reviews, a fuller understanding of contributing factors can be gained, which leads to more accurate and robust findings, and better system improvements. 

In partnership with health services and consumers, we have developed a set of resources that can be used during the review process.

• Consumer involvement following a SAPSE: a 9-step guide
• Consumer & community factsheet: What happens after patient harm?
• Next Steps Pamphlet 

Rachel's story 

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

Policy and guideline

Our Adverse Patient Safety Events policy provides in scope Victorian health services with the requirements, accountabilities and definitions relevant to responding to all types of adverse patient safety events. An accompanying guideline has been published to support health services in enacting the policy.  

The policy was updated in 2023 to incorporate guidance for managing all types of adverse patient safety events, and amendments to the Health Services Act 1988. The policy also now includes reference to the Victorian Duty of Candour Guidelines, and Protections for serious adverse patient safety event review requirements. 

The key principles guiding the development of the Adverse Patient Safety Events policy and guideline include a strong focus on learning and improvement, leadership engagement, just culture and systems thinking, and compassionate consumer engagement.  

The policy provides health services with:   

• key definitions related to adverse event management  
• notification requirements for sentinel events  
• expectations and accountabilities of health services and Safer Care Victoria when responding to adverse events, including the identifying, reporting, notifying, reviewing and monitoring of these adverse events. 

The policy was updated in 2023 to incorporate guidance for managing all types of adverse patient safety events, and amendments to the Health Legislation Amendment (Quality and Safety) Bill 2021. The policy also references the Victorian Duty of Candour Guidelines, and Protections for serious adverse patient safety event review requirements.

Figure 1: Provides a high-level overview of adverse event reporting and review accountabilities for all levels of adverse patient safety events.

The guideline provides health services with supporting information to enact the policy and respond to adverse patient safety events. It provides hands-on guidance on the review and improvement process, including the following elements: 

• setting up and planning the review process 
• forming the review team 
• gathering evidence 
• developing a timeline 
• analysing the data  
• developing findings, recommendations and action plans 
• monitoring recommendations.

Read more tips on reviewing an adverse patient safety event.

You can provide feedback on the policy and guideline to help us with future revisions. 

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

Developing recommendations

This guide provides review teams with practical tips on developing recommendations, what to be aware of and ensuring owners are engaged in development. It outlines how to validate recommendations against the findings and how to measure outcomes.

Download Developing recommendations

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.