Reducing preventable harm to residents in aged care: A systems approach

Peter D. Hibbert, Robyn Clay-Williams, Johanna Westbrook, Richard L. Reed, Andrew Georgiou, Louise K. Wiles, Charlotte J. Molloy, Jeffrey Braithwaite

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)


Residents in Australian aged care facilities can suffer serious preventable harm from incidents (‘adverse events’ (AEs)). An inadequate response to AEs by aged care facilities can compound distress to residents and their families/carers. Facilities have an obligation to respond to and investigate AEs involving residents, learn from them, and take action to reduce the chance of them reoccurring. Residential aged care facilities have a duty to create a culture where staff, residents and families/carers feel comfortable reporting AEs or complaints; there is adequate time and resources to manage AEs and complaints; and feedback is provided to staff, residents and their families/carers on the results of investigations into AEs/complaints. The Aged Care Quality and Safety Commission's role should encompass additional governance functions such as sharing results and lessons learnt from AEs, complaints and investigations across Australia, assuring the quality of investigations conducted by facilities, and undertaking national system-wide investigations.

Original languageEnglish
Pages (from-to)72-76
Number of pages5
JournalAustralasian Journal on Ageing
Issue number1
Early online date2 Oct 2020
Publication statusPublished - Mar 2021


  • homes for the aged
  • patient harm
  • patient safety
  • root cause analysis


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