Tools
In-depth case review tool
The in-depth case review (IDCR) tool assists health services to use a structured, systems-based approach to reviewing adverse patient safety events (APSE).
The IDCR tool is systems-focused, which means it supports reviewers in applying a systems lens when identifying factors that contributed to the adverse event occurring. The tool aligns with contemporary safety science which demonstrates that adverse events in complex systems like healthcare result from multiple interacting factors. More information on when and how to use the tool can be found in the APSE policy and guideline.
Maternal and Child Health Systems – Focused review tool
Maternal and Child Health (MCH) services are predominantly managed and operated by local government. Local governments do not fall under the Health Services Act 1988 (Vic) and are therefore not covered by the relevant protections when a serious adverse patient safety event (SAPSE) review is undertaken. The MCH Systems focused review tool provides MCH services with a systematic approach to client case reviews.
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.
Falls review tool
The Falls Review Tool is available for health services to use, accompanied by a user guide, which contains instructions on how to use the tool for a sentinel event.
The tool assists health services to:
-understand their current risk in relation to falls prevention
-streamline the review process
-use a human factors (systems thinking) approach to reviewing falls
-strengthen recommendations resulting from the review of falls-related adverse events.
Health services are encouraged to familiarise themselves with the updated sentinel event guidance relating to falls.
Fact sheets
These fact sheets 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 fact sheets 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 fact sheet helps you understand how a just culture can help you achieve positive outcomes for consumers and your organisation.
Leadership and safety culture
Safety culture refers to an ongoing organisational commitment to safety by all staff within an organisation. This fact sheet outlines the role that organisational leaders play in building, maintaining and promoting the principles of a safety culture within their organisation.
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.
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 fact sheet will help you understand how human factors contribute to adverse events and helps you undertake a fair review process.
Interviewing for adverse event reviews
Interviews are a key source of evidence to understand what contributed to adverse patient safety events. This fact sheet will help you prepare for interviews and use good interviewing principles to reduce interviewer bias.
Guidance Documents
Adverse Patient Safety Event Review management guide
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.
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.