Medical Device Incidents Workshop

Thursday, 26th March 2009

This national workshop was held to examine the potential for a number of information sources to contribute to meaningful national analysis of clinical incidents. There have been a large number of national and jurisdictional-based initiatives to improve patient safety and to manage and analyse clinical incidents. Most jurisdictions have established systems for incident management and analysis, including implementing computer-based incident reporting systems and criteria for conducting root cause analyses.

National quality improvement may, however, be well served by other ways of sharing information on incidents and the known patterns of risks, including focusing on the results of root cause analyses and 'sharing the learning' from these. Evidence on the efficacy of learning from detailed, qualitative analyses must also be evaluated. Information and evidence, both Australian and international, must be assembled and assessed, in consultation with experts and stakeholders in this very active field, in recommending the best approach nationally. Dr Larry Kelly from the Therapeutic Goods Association was the keynote speaker, and five case studies were presented.

Medical Device Incidents Program and Presentations