Resources

The London Protocol is a well-known framework designed to guide deep analysis of clinical incidents to improve safety. The 2025 revision of the Protocol introduces significant updates to strengthen the analysis of clinical incidents. A key enhancement is the increased emphasis on engaging patients and their families as active partners in the incident analysis process. 

Safer Care Victoria has developed a framework and toolkit to guide Morbidity and Mortality (M&M) meetings to provide health services with a systems-based and Just Culture approach to M&M case reviews and discussions.  

The Commission has released two new resources summarising the evidence on the effectiveness of interventions that aim to improve medication management at transitions of care.

Clinical Guidelines are developed to standardise practice and provide a solid evidence base for care. They are essential components of clinical governance to support safe and effective care and serve as valuable tools for training.  

As this study reveals, guidelines can also be a source of confusion and misapplication. Ambiguities in guidelines can result in varying interpretations among healthcare providers, contributing to inconsistent care and potential patient harm. 

Striking a balance between patient safety and professional autonomy is a complex issue that requires a multifaceted approach. Multiple challenges stand in the way of a balanced approach, such as...

Dignity in healthcare, and particularly in the care of the elderly, is seen as a basic human right, as is the right not to be harmed in the course of care. But are these rights counteracting each other?

This article explores the relationship between the management of clinical risk and the provision of dignified care to older people on acute hospital wards in the NHS. It shows that the care relationship between staff and their patients can be negatively affected by risk management practices that seek to eliminate the inherent uncertainties of clinical care. Ironically, it seems the management of clinical risk can pose a challenge to maintaining dignified care for older people.  

Over the past three decades, the predominant approach to improving safety in health care has involved studying adverse outcomes to identify system vulnerabilities and correct them. While this approach has been useful, it has limitations. A focus only on unfavourable outcomes can limit innovation and adaptability, not to mention undermine worker morale and engagement.

Numerous studies about the use of trigger tools to identify adverse events (AEs) have been performed in hospitals. However, the research conducted on the use of trigger tools to identify AEs in primary care is limited. 

This study developed a set of triggers for identifying adverse events in Primary Care, from health record reviews with high positive predictive value (PPV), making it easier to collect reliable information on care-related incidents in this sector. It also presents interesting data on adverse event prevalence in Primary Care.

Ensuring organisations learn from patient safety incidents is a key aim for human service organisations. The role that human factors and systems thinking can have in enabling organisations to learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems.

James Reason once characterised the goal of error investigations as ‘draining the swamp, not swatting mosquitoes’. Critical incidents arise from the interplay between active failures (eg. not double-checking for allergies before administering a medication) and latent conditions (eg. workload).