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News Article
Australia: Monash IVF admits second bungled embryo implant
Patient Safety Learning posted a news article in News
A second bungled embryo implant at Monash IVF has sparked a new investigation and the expansion of a review into the first incident, which led to a woman unknowingly giving birth to a stranger’s baby. Monash IVF said in a statement on Tuesday that in June “a patient’s own embryo was incorrectly transferred to that patient, contrary to the treatment plan which designated the transfer of an embryo of the patient’s partner”. “Monash IVF has extended its sincere apologies to the affected couple, and we continue to support them,” the fertility company said. The first error was announced in April. In that case, a patient at one of its Queensland clinics had an embryo incorrectly transferred to her, meaning she gave birth to a child of an unrelated woman. The mistake was blamed on human error. Monash IVF asked senior counsel Fiona McLeod to investigate. Lawyers described the incident as a legal and ethical nightmare while Monash IVF said it was confident it was an isolated incident. The latest incident happened in a Victorian laboratory. The state’s health minister, Mary-Anne Thomas, confirmed the Victorian health regulator was investigating. Read full story Source: The Guardian, 10 June 2025 -
Content ArticleMany errors in surgical patient care are caused by poor non-technical skills (NTS). This includes skills like decision-making and communication. How often these errors cause harm and death is not known. This goal of this study was to report how many surgical deaths are associated with NTS errors in Australia by assessing all surgical deaths from 2012 to 2019. Some 64% of cases had an NTS error linked to death. Decision-Making and Situational Awareness errors were the most common. The results of this study can be used to guide improvement and reduce future errors and patient death.
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Content Article
In this blog, Siân Slade shares how, through her research interest into the difficulties of navigating the healthcare system in Australia, she created a policy and advocacy project: #NavigatingHealth. The aims of the project are to streamline the silos and address the fragmentation of healthcare by bringing together all those who are developing solutions to enable patients and carers to better navigate healthcare journeys. Background About 10 years ago, I listened to a friend’s experience navigating cancer and puzzled over the challenges encountered. These made me question my prior assumption of 'patient-centricity' across healthcare. In 2015, the Organisation for Economic Co-operation and Development (OECD) released a report highlighting the complexities of the Australian healthcare system. This led me to realise that while we do have patient-centred care, it is often provider dependent, not system-wide, and relies on the patient (or carer) to navigate the system; a time when individuals are at their most vulnerable. Given 'the standard you accept is the standard you walk past”, I decided to do 'my bit' to address this. I enrolled in a Master of Public Health, researching healthcare navigation in Australia. I found there was a fragmented approach to try and address an already fragmented problem. This led me to embark on a PhD as well as develop a policy and advocacy platform: #NavigatingHealth. Setting up a national network and community of practice My focus has always been on a practical approach that solves problems for individuals but also seeks to understand how to scale these at a systems level to sustain change in the long-term. If this was a known problem, why was nothing being done to address it? Surely this was something government were addressing... or there must be an app? I spoke to lots of people—patients, carers, speakers at conferences, those who had written books of their healthcare experience and, yes, those developing apps. Everyone agreed it was a problem, but nothing was addressing the totality of the problem. The problem was not just in navigating healthcare, but also the challenges navigating related systems, such as those for people with disabilities, or for aged care, as well as social services and education. #NavigatingHealth started life as two, 60-minute webinars held in mid and late September 2021, supported by the Australian Disease Management Association. The inaugural webinar speakers provided vignettes across a life journey—from childhood through to getting older—based on their own lived-experiences as patients, carers or professionals (not-for-profit, health services and government). The positive reception of the webinars led to setting up a bimonthly national network and community of practice in Australia that ran until the end of 2024. The meetings were deliberately not recorded to build a safe space for people to share ideas, build tacit (word of mouth) knowledge and a like-minded solutions focused community. Summaries of all the events and speakers are available on the #NavigatingHealth project page. In health, information and projects evolve. Building an online community was low-cost and accessible to everyone. The success of the Australian approach led to a series of global webinars using the same format of expertise provision from individuals in research, policy, and advocacy and health services. The first global webinar was held in 2022 attracting over 20 countries. Connecting and collaborating The 'glocal' community continues to grow. Projects are constantly evolving, elevating and expanding as well as exiting often impacted by funding constraints. In the spirit of a complex adaptive learning health system, core to our success is the community knowledge built through relationships, trust, like-values and non-linear interactions. Taking an approach that is resourceful versus one requiring constant resourcing (we use accessible tools such as LinkedIn and more recently Bluesky) to provide an effective, free platform to keep individuals in touch with one another. Our dedicated #NavigatingHealth project page on the Nossal Institute for Global Health website at the University of Melbourne acts as a central hub for events and resources. The genesis during the pandemic and expansion virtually through Teams and Zoom, as well as in-person post-pandemic, has enabled different ways to expand the national community, the global network and we welcome all-comers. The project is voluntary and our success is based on linking people, developing relationships, sharing expertise, maintaining momentum and the opportunity we all have to impact into #NavigatingHealth. The annual forums, 2024 #NavigatingHealth Simplifying Complexity and 2025 #NavigatingHealth Enabling Patients, System-Wide, focused on bringing together colleagues nationally in Australia. The in-person workshops created the opportunity to build community, share ideas, leverage learnings and also provide educational content. These collaborations have allowed development of materials for curriculum and teaching, and an evolving conversation about the importance of systems-thinking. We developed a short global project collecting stories from individuals who are happy to be involved. Our video, NavigatingHealth - why this matters, provides a glimpse of our approach. Looking forward The Future of Health Report published in 2018 highlights that our health systems, locally and globally, will change from 'one size fits all' to one that is personalised. The challenge is how? Future of Health Report, CSIRO 2018. The 'secret sauce' is that by working collaboratively we can all be part of evolving and effecting systems change. The work is underpinned by equity and a focus on enabling early access to care, addressing barriers, such as financial or cultural constraints, and helping to make visible information asymmetries and power imbalances to ensure effective collaboration and co-production. Building on the success of our past forums, planning for 2026 is underway. Block out 1 April 2026 in your calendar for the inaugural #NavigatingHealth Day! Our collective expertise is our power—let’s do this! Want to know more? Please get in touch with Siân at [email protected] or via LinkedIn. Further reading on the hub: The challenges of navigating the healthcare system How the Patients Association helpline can help you navigate your care Lost in the system? NHS referrals -
Content ArticleRacism is a fundamental determinant of health, contributing to health inequities globally. It is a frequent experience for Aboriginal and Torres Strait Islander peoples and shapes their experience of cultural safety in healthcare and other settings. This policy brief outlines the importance of cultural safety in addressing racism, the need for clarity and understanding about cultural safety, and creating pathways for embedding cultural safety in health and human services through establishing national training standards and a linked accreditation process, combined with dedicated organisational action.
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Content ArticleThe Australian Commission on Safety and Quality in Health Care released a set of national standards which became a mandatory part of accreditation in 2013. Standard 9 focuses on the identification and treatment of deteriorating patients. The objective of the study was to identify changes in the characteristics and perceptions of rapid response systems (RRS) since the implementation of Standard 9. The authors concluded that implementing a national safety and quality standard for deteriorating patients can change processes to deliver safer care, while raising the profile of safety issues. Despite limited dedicated funding and staffing, respondents reported that Standard 9 had a positive impact on the care for deteriorating patients in their hospitals.
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News ArticleTwo women who police allege practised as unregistered midwives have been charged with manslaughter after a baby died after a home birth on the New South Wales mid north coast. The women, aged 41 and 51, appeared in Coffs Harbour local court on Wednesday in relation to the newborn boy’s death in 2022. Emergency services were called to a home in Karangi, north-west of Coffs Harbour, when the baby was unresponsive after the home birth on 11 September 2022, NSW police said in a statement. Paramedics treated the baby before he was airlifted to Coffs Harbour base hospital where he died. Police allege the younger woman was an unregistered midwife at the time of the birth while the older woman held no medical qualifications and had been practising unregistered home-birth midwifery. Read full story Source: The Guardian, 13 March 2025
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Content Article
Patient Experience Agency website
Patient-Safety-Learning posted an article in Suggest a useful website
The Patient Experience Agency is an Australian consultancy that aims to change the approach of healthcare providers towards delivering exceptional patient experiences. They want to see a healthcare sector in Australia that works in partnership with its patients, embraces a team-based, data-driven approach, constantly monitors experiences and outcomes and uses patient insights to continuously improve. -
News ArticleSensitive patient information has allegedly been leaked on the dark web after Genea, one of Australia’s leading IVF and fertility services providers, was hacked a fortnight ago. The attack was allegedly carried out by the Termite ransomware group, prompting Genea to obtain a court injunction on Wednesday that criminalises access to the breached patient data. In a statement, Genea said: “Our ongoing investigation has established that on the 26 of February, data taken from our systems appears to have been published externally by the threat actor.” “We understand that this development may be concerning for our patients for which we unreservedly apologise.” Sensitive information including contact details, Medicare card numbers, medical histories, test results and medications may have been compromised in the data breach, Genea said, and it was “working to understand precisely what data has been published”. Read full story Source: the Guardian, 26 February 2025
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Content ArticleThe National Medicines Symposium 2024 session recordings are now available. Whether you missed a session or want to revisit the insightful discussions, you can now explore the key highlights from the event. Panel highlights to explore: Managing Medicines for an Ageing Population – Hear from Professor Jennifer Martin, Professor Libby Roughead and Mr Steve Waller on challenges of medication safety in an ageing population such as polypharmacy and multimorbidity and opportunities for improvement. Deprescribing in Practice – Join Professor Sarah Hilmer AM, Dr Lisa Kouladjian O’Donnell and Professor Jenny May AM as they explore practical approaches to safely deprescribe medications when the risks outweigh the benefits, ensuring patient safety. Digital Tools for Safe Medication Use – Gain insights from Professor Melissa Baysari, Mr Michael Bakker, Ms Kate Oliver and Ms Alice Nugent on how innovative digital tools can be leveraged to enhance medication management.
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Content ArticlePaper reporting on a scoping review that sought to ‘synthesise and summarise existing evidence for implementing and evaluating Cultural Safety initiatives in Australian hospitals for Aboriginal and Torres Strait Islander peoples’ with a view to identifying best practices. Based on 9 studies, the review identified 5 themes: Process of implementation. Process of evaluation. Change in health professional’s behaviour. Change in patient behaviour. Future recommendations. The authors conclude that ‘significant improvement is needed in adopting evidence-based and carefully considered approaches to implementing and evaluating Cultural Safety initiatives in hospital settings. Specifically, implementation should be underpinned by a validated theoretical framework and consider and address potential practical barriers in engaging health practitioners.’
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Content ArticleThe CovidD-19 pandemic challenged primary care to rapidly innovate. In response, the Western Victorian Primary Health Network (WVPHN) developed a Covid-19 online Community of Practice comprising general practitioners (GPs), practice nurses, pharmacists, aged care and disability workers, health administrators, public health experts, medical specialists, and consumers. This Experience Report describes the progress towards a durable organisational learning health system (LHS) model through the Covid-19 pandemic crisis and beyond. In March 2020, WVPHN commenced weekly Community of Practice sessions, adopting the Project ECHO (Extension of Community Health Outcomes) model for a virtual information-sharing network that aims to bring clinicians together to develop collective knowledge. The work was underpinned by the LHS framework proposed by Menear et al. and aligned with Kotter's eight-step change model. There were four key phases in the development of our LHS: build a Community of Practice; facilitate iterative change; develop supportive organisational infrastructure; and establish a sustainable, ongoing LHS. In total, the Community of Practice supported 83 unique Covid-19 ECHO sessions involving 3192 h of clinician participation and over 10 000 h of organisational commitment. Six larger sessions were run between March 2020 and September 2022 with 3192 attendances. New models of care and care pathways were codeveloped in sessions and network leaders contributed to the development of guidelines and policy advice. These innovations enabled WVPHN to lead the Australian state of Victoria on rates of COVID vaccine uptake and GP antiviral prescribing. The Covid-19 pandemic created a sense of urgency that helped stimulate a regional primary care-based Community of Practice and LHS. A robust theoretical framework and established change management theory supported the purposeful implementation of the LHS. Reflection on challenges and successes may provide insights to support the implementation of LHS models in other primary care settings.
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Content ArticleProfessor Peter Hibbert from the Australian Institute of Health Innovation reflects on how HSSIB contributes to improved patient safety, and their education offering and areas for improvement.
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Content ArticleThis status report by the Australian Commission on Safety and Quality in Healthcare looks at achievements against the recommendations in 'Medication without harm – WHO Global Patient Safety Challenge: Australia’s response'. The report examines data published to the end of June 2023 and published papers to the end of February 2024. It examines the impact of programs implemented to address the priority actions identified in the three WHO flagship areas: Monitoring polypharmacy and responding to inappropriate polypharmacy Reducing harm from high-risk medicines, with focus on insulin, opioid analgesics, anticoagulants and antipsychotics Improving medication safety at transitions of care.
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Content ArticleSafer Care Victoria, Australia, has released their first Victorian Safety Culture Guide (VSCG). The guide is intended to support healthcare leaders to measure and monitor their organisation’s safety culture. According to the SCV, the Guide: facilitates proactive measurement and monitoring to prevent harm and promote safer, continuously improving health care offers actionable strategies, practical approaches, and best practices for improving safety culture across all Victorian healthcare services allows leaders to make data-driven decisions to support the implementation of targeted changes to improve safety culture uses a variety of existing methods and approaches widely available in most Victorian health services.
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EventJoin the webinar to find out how the community sector can implement the National Safety and Quality Mental Health Standards for Community Managed Organisations (NSQMHCMO Standards). The Australian Commission on Safety and Quality in Health Care is releasing a range of practical resources to support CMO service providers, consumers and carers, and accrediting agencies to implement the NSQMHCMO Standards. Accreditation to the NSQMHCMO Standards begins 1 July 2024. Register now to find out about what the Standards mean for you and how you can prepare for the accreditation process. Register
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Community PostAbout 1000 angry nurses and doctors have rallied outside Perth Children’s Hospital in Australia following the death of seven-year-old Aishwarya Aswath, demanding vital improvements to the state’s struggling health system. The Australian Nurses Federation was joined by the Australian Medical Association for the rally, with staff from hospitals across Perth attending. Many people held signs that read “We care about Aishwarya”, “Listen to frontline staff”, “Report the executive — not us” and “Please don’t throw me under the bus”. Aishwarya developed a fever on Good Friday and was taken to Perth Children’s Hospital the next day, but had to wait about two hours in the emergency department before she received treatment. She died soon after from a bacterial infection. An internal report into the tragedy made 11 recommendations — including improvement to the triage process, a clear way for parents to escalate concerns and a review of cultural awareness for staff — but Aishwarya’s parents said the report raised more questions than it answered. The family wants a broader independent inquiry to look at all 21 near-misses in the past 15 months – not just their daughter’s case. Some people have been referred to medical authorities, while Child and Adolescent Health Service chair Debbie Karasinski resigned after the report.' I am encouraged to see the way healthcare staff reacted to this tragedy. Imagine a similar event in England, would nurses protest outside the hospital and stand up to authority like this? I doubt it very much, which is very sad reflection on the prevailing culture and health leadership in England. What do others think? Source: The Australian. 9 July 2021 Picture: Picture: 9 News
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Content ArticleThis study aimed to operationalise and use the World Health Organization's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths.
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Content ArticleThe Australian Disability Royal Commission was established in April 2019 in response to community concern about widespread reports of violence against, and the neglect, abuse and exploitation of, people with disability. These incidents might have happened recently or a long time ago. The Disability Royal Commission will investigate: preventing and better protecting people with disability from experiencing violence, abuse, neglect and exploitation. achieving best practice in reporting, investigating and responding to violence, abuse, neglect and exploitation of people with disability. promoting a more inclusive society that supports people with disability to be independent and live free from violence, abuse, neglect and exploitation. The Disability Royal Commission gathers information through research, public hearings, the personal experiences people tell us about and submissions, private sessions, and other forums. It will deliver a final report to the Australian Government by 29 September 2023. The Disability Royal Commission publishes progress reports at intervals of approximately six months. The reports are primarily intended to provide a brief account of the Royal Commission’s activities over the preceding half-year period. The Interim Report was published on 30 October 2020. It sets out what the Royal Commission has done in its first 15 months. The report says people with disability experience attitudinal, environmental, institutional and communication barriers to achieving inclusion within Australian society. It shows that a great deal needs to be done to ensure that the human rights of people with disability are respected and that Australia becomes a truly inclusive society. Private sessions factsheet: Over the course of the Royal Commission, almost 10,000 people shared their experience of violence, abuse, neglect and exploitation by making a submission or participating in a private session.
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Content ArticleIn Australia, as in many other countries, the harms caused by transvaginal mesh surgery have prompted individual and collective attempts to achieve redress. Media outlets covered aspects of the rise of mesh surgery as a procedure, the experience of mesh-affected women and the formal inquiries and legal actions that followed, The authors of this article in the journal Health Expectations conducted a media analysis of the ten most read Australian newspapers and online news media platforms, focusing on how mesh and the interaction of stakeholders in mesh stories were presented to the Australian public. They found that mass media reporting, combined with medicolegal action and an Australian Senate Inquiry, appears to have provided women with greater epistemic justice, with powerful actors considering their stories. They argue that although medical reporting is not recognised in the hierarchy of evidence embedded in the medical knowledge system, in this case, media reporting has contributed to shaping medical knowledge in significant ways.
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Content ArticleThe aim of this Australian study was to assess the impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes using administrative health data. The results suggest that the introduction of assistants in nursing into ward staffing in an additive role should be done under a protocol which clearly defines their role, scope of practice, and working relationship with registered nurses, and the impact on patient care should be monitored.
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News Article
Australian doctor suspended amid investigation into woman’s death after abortion
Patient Safety Learning posted a news article in News
A doctor working at a women’s health clinic in Melbourne has been suspended as a regulator revealed it was aware of concerns about other practitioners there. The facility’s boss claims it is a “witch hunt”. It follows the death of 30-year-old mother Harjit Kaur, who died in January at the Hampton Park Women’s Clinic after what was described as a “minor procedure”. It was later identified as a pregnancy termination. The Australian Health Practitioner Regulation Agency (Ahpra) has confirmed Dr Rudolph Lopes’ registration had been suspended but did not reveal the reason behind the decision. His registration details show he was reprimanded in 2021 for failing to respond to the regulator’s inquiries. “[The regulator] has received a range of concerns about a number of practitioners associated with the Hampton Park Women’s Clinic,” Ahpra said in a statement. “[The regulator] has established a specialist team to lead a co-ordinated examination of these issues which involve multiple practitioners across a number of professions and across a number of practice locations.” Ahpra chief executive, Martin Fletcher, said he was “gravely concerned by the picture that is emerging.” “We have taken strong action to protect the public while our investigations continue,” Fletcher said. “National boards stand ready to take any further regulatory action needed to keep patients safe. “While the coroner continues to examine the tragic death of a patient, our inquiries are focusing on a wider range of issues that our investigations bring to light.” Read more Source: The Guardian, 15 March 2024 -
EventuntilTe Ngāpara Centre for Restorative Practice invites you to attend the virtual symposium Restorative Health Systems: Healing, learning, and improving after harm. This free event is being held in association with the Health Quality & Safety Commission in Aotearoa New Zealand. The symposium will provide a virtual space for knowledge sharing and exchange among the growing international community of clinicians, researchers, consumers, investigators policymakers, and practitioners working in health settings. We aim to share what is happening globally in this emerging field and to reflect on the future of restorative initiatives in the health system context. The symposium will incorporate a series of different sessions, including interactive dialogues with international critical thinkers and advocates, presentations on key issues relevant for the field and research relating to restorative initiatives. View the programme (PDF) This is the first of a symposium series as part of the Te Ngāpara Centre for Restorative Practice’s commitment to supporting the development of restorative knowledge. The symposium will take place on Zoom on Wednesday 29 March, 8am - 12pm (NZDT) 0600 Australia (AEDT) 2000 London UK (BST) 1200 Vancouver (PDT) 1500 Montréal (EDT) Register for the symposium
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EventWe live in a world marked by massive global changes, moving us rapidly into rather unprecedented and unknown directions. It has never been so vital for us to understand the interactions among humans and other system elements. This necessitates the creation and adoption of theories, principles, data, and methods of design, as well as new capabilities, technologies, skills, procedures, policies, strategies to find new ways of engaging with a rapidly changing world and optimise wellbeing and performance. Find out more at the Human Factors & Ergonomics Society of Australia (HFESA) virtual conference. Register
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News Article“Gut-wrenching,” says Lisa McManus. She is looking for words to describe how she and other thalidomide survivors feel ahead of a historic apology by Anthony Albanese for government failings in the tragedy. She is grateful for recognition of the medical disaster and relieved that a decade of advocacy has come to fruition. Around 80 of the 146 recognised survivors will witness the apology in Canberra on Wednesday in what McManus hopes will be “a step in the healing process”. But she is also frustrated that too many others have not lived to see the day. Thalidomide caused birth defects including “shortened or absent limbs, blindness, deafness or malformed internal organs”, according to the Department of Health. The drug was not tested on pregnant women before approval, and the birth defect crisis led to greater medical oversight worldwide, including the creation of Australia’s Therapeutic Goods Administration. Survivors and independent reports have criticised the government of the day for not acting sooner to remove thalidomide from shelves when problems became apparent. McManus leads Thalidomide Group Australia, having lobbied governments for a decade for an apology and better support. She’s “extremely grateful” for the apology, and says many survivors are anxious, excited and nervous – but that the apology itself can’t be the end. “I’m relieved it’s happening, I just can’t say ‘thank you’,” McManus says. “I’m very happy to think it’s here, but it won’t fix things, and I don’t want the government thinking they will deliver this and it’ll all be fine.” Read full story Source: The Guardian, 28 November 2023
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Content Article“Sunshine” policy, aimed at making financial ties between health professionals and industry publicly transparent, has gone global. Given that transparency is not the sole means of managing conflict of interest, and is unlikely to be effective on its own, it is important to understand why disclosure has emerged as a predominant public policy solution, and what the effects of this focus on transparency might be. Grundy et al. used Carol Bacchi’s problem-questioning approach to policy analysis to compare the Sunshine policies in three different jurisdictions, the United States, France and Australia. We found that transparency had emerged as a solution to several different problems including misuse of tax dollars, patient safety and public trust. Despite these differences in the origins of disclosure policies, all were underpinned by the questionable assumption that informed consumers could address conflicts of interest. The authors conclude that, while transparency reports have provided an unprecedented opportunity to understand the reach of industry within healthcare, policymakers should build upon these insights and begin to develop policy solutions that address systemic commercial influence.
