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Patient safety—a view from down under
  1. Merrilyn Walton
  1. PPD Sydney Medical Program, Office of Postgraduate Medical Education, Sydney Medical School, University of Sydney, NSW 2006, Australia
  1. Correspondence to Merrilyn Walton, m.walton{at}

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In “Transforming Health Care: A Safety Imperative”,1 Leape et al highlight the slow progress towards safe healthcare (see page 424). They notice that efforts in the USA to improve healthcare have fallen short. They conclude that only a transformation of healthcare can deliver safer care and better health outcomes. They identify transforming concepts, all pertinent and familiar.

Minimising errors has been central to Australia-wide efforts to improve healthcare since 1995 when the Australian Health Care Study was published.2 In Australia, as elsewhere, there are many enclaves of excellent care; they are testimony to human resilience and enlightened healthcare workers. What is it about these safe healthcare professionals and why aren't their attributes universal? Have we focused on the right parts of healthcare in our attempts to make improvements? Have our efforts in Australia made a difference?

Improved healthcare can ultimately lead to a transformation in the way care is delivered. Take complaints. Independent health complaint commissions established by states and territories have transformed the way complaints are managed. Important lessons are identified and passed on. From 1985 to 2000, I was responsible for complaints about health services and healthcare professionals in New South Wales. Patient complaints were the first indicators of the extent of adverse events. During the 1980s, an adverse event experienced by a patient and later complained about was not taken seriously by the providers or hospital management. Patients or carers were commonly told that all care had been taken and that the harm suffered was due to their condition or a complication and not to any failure by providers or management. Observations by those outside healthcare about quality and safety were ignored or dismissed.

During the 1990s when country after country published studies exposing the extent of harm in healthcare, governments and patient safety experts grappled with the knowledge that the system of healthcare, as opposed to individual action, was causing significant harm to patients. Unfortunately, these findings were not shared with patients. Since 2000, we have come to realise that our failures in healthcare cannot be hidden and that patients are entitled to know the extent of harm caused by healthcare as well as what we are doing to make the system safer.

The implementation of open disclosure Australia-wide has been possible because of the increased awareness of patient experiences of their adverse events and the role the complaint commissions have played over the last 20 years. In 2008, Australian Health Ministers agreed to implement nationwide the Open Disclosure Standard. Creating an expectation that patients will have complete and honest information provided after an adverse event is in itself transforming; it re-establishes the human connection between patients and providers. It allows, indeed expects, providers to drop their defences and engage with patients as human beings. It reconnects them as people rather than adversaries. It is the platform for examining and understanding what happened and why.

In Australia, national initiatives are enabling genuine partnerships (relationships) between the health system, healthcare workers, patients and the community. I believe these relationships have the potential to transform healthcare.

Relationships between patients and their providers

Consumers have been members of health advisory boards in Australia for decades, but there is little evidence that their inclusion has led to patient-centred healthcare. This is not to say that they should not have a seat at the table; they should. But until patients are fully engaged in their own healthcare by providers (the team), it will be difficult for the system to become more patient centred. The very act of engagement changes the relationship and the context in which care is provided. It is the touchstone for transforming a provider healthcare system to a patient-centred one.

In 2008, Australian Health Ministers endorsed the Australian Charter of Healthcare Rights.3 The charter puts patients in the picture. Many patients know their safety depends on the healthcare team—doctors, nurses, allied health and ward staff. They want more information, to be part of the team, but many health professionals today see the patient role as a passive one. Patients are usually told what is wrong with them, how, where and when their condition will be treated and by whom.4 Patients are not expected to make decisions other than whether they will have the treatment or not. Patients are not encouraged to ask questions, make enquiries about the safety and quality of services such as infection rates and adverse events, or inquire about the level of skill and knowledge of the people treating them. They have been left behind at a time when significant changes have been taking place. Today, better organised hospitals employ accredited health professionals,5 services are more complex, yet there has been no concomitant adjustment in the role of patients. At a time when patients need more involvement—because of the complexity of care and the risks associated with the many interventions and drugs—they are still less involved. The charter affirms patients' voices in a healthcare culture that still views patient engagement as optional and of questionable value.4

Education of the workforce

We cannot expect healthcare professionals to know how to engage with patients and keep them safe if we do not prepare them. In 2006, the Australian Health Ministers endorsed the National Patient Safety Education Framework6 that identifies all the competencies (knowledge, skills and behaviours) required to keep patients safe. This generic and flexible framework is evidence-based, patient centred and focused on a healthcare workers' level of clinical responsibility rather than their profession. The internationally endorsed framework has been used by many different professions, universities and health organisations to develop curricula; the WHO Patient Safety Curriculum Guide for Medical Schools, Australian Curriculum Framework for Junior Medical Officers, Hospitalist programme in New South Wales, US Patient Safety Education Programme (North Western University) and College of Physician training programme (Australia) are just a few.

National registration

In 2008, the Australian Health Ministers also agreed to create the Australian Health Practitioner Regulation Agency as a single national regulation and accreditation scheme for the 10 main health professionals. The new scheme, to come into effect on 1 July 2010, will protect the public by ensuring that practitioners who are registered are suitably trained and qualified to practice in a competent and ethical manner. It will also facilitate the provision of high-quality education and training. A single national registration scheme is the cornerstone to embedding patient safety concepts and principles in all health professional education and training as well as codes of conduct.

Community and governments

Governments have established patient safety commissions or bodies to lead safety and quality in healthcare through advocacy of safety and quality, publicly reporting national data sets, strategic advice to health ministers and developing nationally agreed standards.

National standards for basic care cover healthcare-associated infection, national hand hygiene, patient identification, medication safety, clinical handover, recognition and response to clinical deterioration, falls guidelines, standardising terminology, abbreviations and symbols for use in hospital prescribing, labelling parenteral medicines, lines and fluids, accreditation and credentialing (scope of practice).

State and territories have implemented incidence management and monitoring systems. States such as New South Wales are making the reports available to the public. The NSW Clinical Excellence Commission's annual reports of incident (Incident Information Management System) data collected by the Department of Health through its mandatory incident reporting system has been a major step in explaining to the public the complexities in today's healthcare.


A transformed healthcare system places patients firmly in the centre. A place in which healthcare workers are educated and trained to deliver patient-centred care as members of multidisciplinary teams, using the best available evidence and ethical practice, quality improvement approaches and information technology. In Australia, we have started this journey. Since 2005, we have developed significant patient safety curricula at all levels to prepare our future workforce. In addition, there is consensus on major areas such as open disclosure, national registration, handover, infection control and patient identification. State and territory health ministers have provided leadership. Safety and quality commissions are driving efforts for greater standardisation and transparency. With such support, healthcare workers and patients may together begin the journey towards a transformed healthcare system as identified by Leape and his colleagues.



  • Competing interests None declared.

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