Three newly published studies led by Professor Peter Hibbert from the Australian Institute of Health Innovation offer a comprehensive look at how health services review and learn from harm. The findings highlight the need for a more strategic, systems-based approach to patient safety investigations, with key recommendations including:

• making patient and family needs central to reviews
• improving independence and professionalism in review processes
• aggregating safety data to guide strategic responses
• focusing resources on system improvement, not just incident investigation.

The research also reveals persistent challenges, such as under-resourced review teams, low staff engagement, and a narrow focus on individual error rather than systemic issues. Importantly, it highlights the benefits – and barriers – of involving consumer representatives in safety investigations.

Read the studies:

• Frontiers in Health Services
• BMJ Quality & Safety
• Health Expectations

Professor Hibbert notes, “Behind each review is a patient and family who may have suffered significant harm and staff who may also have been distressed and traumatised. We owe it to them to incorporate what we have learned from this research into future safety investigations.”

AIHI acknowledges funding from the NHMRC and the support of the Clinical Excellence Commission, Safer Care Victoria, Clinical Excellence Queensland, ACT Health, and the Australian Commission on Safety and Quality in Health Care for this research.

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