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
Please consider the patients, their families, carers or friends during the review process. Families can provide crucial and insightful information.
Openly communicate with patients and their families/carers.
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: 17 Dec 2020