1. Form a review team
Avoiding delays in your review will help you identify and act on areas that can be improved.
Find an external expert to help
Health services should have at least one independent member on their serious and sentinel event review panels.
Include a consumer representative
A consumer representative will help you understand the patient perspective and highlight areas for improvement.
Involve patients and families
Patients, families, and carers who are impacted by serious adverse patient safety events have the right to contribute to the review. They often have valuable information that the review team may not be aware of and can identify opportunities to improve the process that are practical and person-centred. Listening to consumers, validating their concerns and including them in the review process can also help alleviate feelings of anger, frustration or mistrust that can develop if they feel left out of the process.
We’ve developed a pamphlet for you to print and give to consumers to explain the review process and invite them to get involved. When printing, print in colour, double-sided, and select 'Flip pages on short edge'.
Download Next steps...
We’ve also developed Next steps – usage instructions on how to use this resource.
2. Conduct the review
Keep performance issues separate
Adverse patient safety event reviews should not be used to manage the performance of staff.
Manage review records and documents
All documents created during the adverse patient safety event review should be carefully distributed and securely stored.
3. Develop, implement and monitor recommendations
Develop recommendations to eliminate, control or accept causal/contributory factors.
Make sure you follow up on whether they are implemented and track their impact on patient safety.
Reviewing events when patient deterioration was missed
Listen to this interview with Alfred Health's Rural Urgent Care Nursing Capability Development Program, where SCV's Joanne Miller talks about critical factors in missed patient deterioration.
Last updated 27 Aug 2019
Page last updated: 10 Oct 2022