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.

Safer Care Victoria helps 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. Read more about these changes.

We are developing resources to help health services prepare for and implement duty of candour. 

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.

COVID-19 deaths in hospitals review tool

We have developed a systems-focused rapid tool specifically for the review of COVID-19 related adverse events within 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.

Helping you find review team members

External reviewers

Our PEER platform will connect you with an independent member for your review team.

Consumer members

Download our guide to working together with consumers to review adverse patient safety events.

Training for healthcare workers and consumers

We conduct regular training in adverse patient safety event reviews.

View our events calendar to find the next available session.