Co-designing with consumers for best practice
This research aims to make the health system safer for patients. It is four-year project born from a common frustration of patient safety-adverse events continuing despite significant investment in investigations and reviews.
Project sponsor: National Health and Medical Research Council (NHMRC) Partnership Grant
Full project name: Improving the health system’s response when patients are harmed: a mixed-methods study
About the project
Around one in every 10 patients suffer a patient safety incident (or adverse event) as a result of their care. Every year, over three million deaths worldwide are due to adverse events, of which about 50 per cent are preventable.
When patients are harmed, it is necessary for healthcare organisations to respond to and learn from them, and attempt to prevent other patients from suffering a similar incident. Despite this, there is a lack of understanding of how incidents should be optimally reviewed or managed and there is no evidence that incident analysis and review are effective in reducing the frequency of harm to patients.
This research project will involve:
- co-designing a set of best practice principles and incident analysis and review support tools
- feasibility testing of a re-engineered process to respond to serious patient safety incidents in one to two facilities
- sharing lessons from the research nationally and internationally.
Project goals
The goal of this project is to develop and integrate evidence-based methods into practice and provide state and national guidance to improve the response and learning when patients are harmed from serious patient safety incidents.
Three broad aims guide this research:
- evaluate current and new methods to improve response to serious incidents
- develop and test methods, including integrating artificial intelligence tools, to improve the response to lower harm incidents
- undertake a cost analysis of the incident reporting process.
Project lead: Professor Peter Hibbert
- Dr Gaston Arnolda
- Dr Elizabeth Austin
- Dr Mia Bierbaum
- Dr Lorelle Bowditch
- Professor Jeffrey Braithwaite
- Professor Robyn Clay-Williams
- Professor Farah Magrabi
- Dr Ryan McMullan
- Charlotte Molloy
- Dr Virginia Mumford
- Dr Brona Nic Giolla Easpaig
- Dr Penelope Sweeting
- Dr Ying Wang
- Professor Johanna Westbrook
- Dr Yinghua Yu
Other project members and collaborators
- Matthew Ames – Independent Consumer Advisor
- Jenny Berrill – Independent Consumer Advisor
- Louise Botha – Canberra Health Services
- Steven Bowden – Clinical Excellence Commission, NSW
- Dr Patricia Bradd – Clinical Excellence Commission, NSW
- Duncan Brown – Independent Consumer Advisor
- Dr Carl De Wet –South West Hospital and Health Service
- Zoe Fernance – Independent Consumer Advisor
- Suchit Handa – Australian Commission on Safety and Quality in Health Care
- Professor Gillian Harvey – Flinders University
- Dr Lynnette Knowles – Darling Downs Hospital and Health Service, Qld
- Professor Raghu Lingham – UNSW
- Professor Sandy Middleton – Australian Catholic University
- Jennifer Morris – Independent Consumer Advisor
- William O’Sullivan – Safer Care Victoria
- Professor Greg Peterson – University of Tasmania
- Professor Paul Salmon – University of Sunshine Coast
- Kirstine Sketcher-Baker – Clinical Excellence Queensland
- Girish Swaminathan – Australian Commission on Safety and Quality in Health Care
- Dr Debra Tennett – Darling Downs Hospital and Health Service, Qld
- Catherine Trevorrow – ACT Health
- Liat Watson – Independent Consumer Advisor
- Mark Zacka – Northern Sydney Local Health District, NSW
The NHMRC Partnership Grant is in partnership with:
- four Australian public health systems and associated care quality agencies:
- the Clinical Excellence Commission
- Safer Care Victoria
- Clinical Excellence Queensland
- ACT Health
- three university partners:
- University of New South Wales
- University of the Sunshine Coast
- Australian Catholic University
- the Australian Commission on Safety and Quality in Healthcare.