Australian Patient Safety Foundation


APSF Annual Report 2013-14 released


The APSF's Annual Report for the most recent financial year (2013-14) is now available for download.

Throughout 2013-2014 the APSF has continued its role as a national, independent organisation for collecting and analysing adverse events and near misses. In particular, ongoing specialist incident reporting projects with Royal Australian and New Zealand College of Radiologists (RaER, and the Australasian College of Emergency Medicine (EMER, have contributed to patient safety in both of these disciplines.

Click here download a copy of the Annual Report in pdf format.

APSF has moved to SAHMRI


In early December, APSF staff packed up the office and moved to the South Australian Health and Medical Research Institute (
SAHMRI opened in 2014 and is located on North Terrace in the 'West End' of the Adelaide central business district. It is the centrepiece of the West End's world-class precinct of medical research and clinical application, with state of the art laboratories and equipment in a purpose-built, iconic, 25,000 square-metre facility, adjacent to the site of the new Royal Adelaide Hospital (new RAH).
APSF staff are based on level 8 SAHMRI, and are co-located with the School of Population Health, University of South Australia. We will luckily still retain our functional links with the School of Psychology, Social Work and Social Policy and at the same time enjoy great views of Adelaide Oval, River Torrens, the CBD and Adelaide Hills.

Australasian Conference on Error in Medical Imaging - Update


Planning for the conference is in full swing and the organising committee is excited to make the following announcements:

  • Confirmation of two sponsors:
  • Finalisation of the academic program
  • A concurrent session of workshops on
    • What to do when something goes wrong
    • Effective communication strategies
    • RaER incident analysis and case studies
  • Hosting of the welcome reception at historic Ayres House

We're looking forward to welcoming all participants to what is shaping to be another excellent event. More information is available from the conference website:

Adverse reactions to contrast media


The second in a three part series of case studies examining adverse reactions to contrast media, which are used in a number of radiological procedures (including computed tomography, CT) has been recently published in the Royal Australian and New Zealand College of Radiologists' newsletter 'Inside News'. Publication of case studies from the RaER (Radiology Events Register, are being led by APSF Research Fellow Anita Deakin.

The first case study examined the prevalence of reactions, which can range from mild rashes to life threatening anaphylaxis, and risk factors for patients. This is available for viewing at: The second case study discussed ways to reduce the risk of contrast media reactions for patients, and treatment options, and is available at:

A final case study is planned for the next edition of 'Inside News'. See the RaER website for more details about the database.

One day workshop on patient safety for Radiation Oncology and Radiology


There is a lot of activity in radiology patient safety planned for the second half of 2014.

In addition to the APSF's 'Australasian Conference on Error in Medical Imaging' in Adelaide on November 21-22, 2014, a one day workshop on patient safety for Radiation Oncology and Radiology is taking place on Wednesday 3rd September 2014 at the Melbourne Conference Centre. The workshop is aimed at health professionals working in radiation oncology and radiology. Participants will receive a practical introduction to patient safety, enabling participants to begin to evaluate patient safety at their workplace. The emphasis is placed on a team-based approach, with active participation of national and international faculty and participants through discussions and group exercises. Visit more information or download the workshop flyer.

Launch of Conference Website


The APSF is excited to announce the launch of the website for the 3rd Australasian Conference on Error in Medical Imaging, to be held in Adelaide from Nov 21-22, 2014.
Financial members of APSF receive a healthy discount on registration fees - please see the website for more information:
Please email for any queries about the Conference.

Clinical Governance - Strengthening quality, safety & performance


Criterion Conferences are hosting a 2-day conference on "Clinical Governance - Strengthening quality, safety & performance".

The conference will be held at L'Aqua, Cockle Bay, Sydney on 18-19th June 2014.

Australian Patient Safety Foundation members quote CC*APSF when registering to SAVE $100 off the current price!

Hear key contributions from

  • Jean McRuvie, Chief Executive Officer, Central Queensland Medicare Local
  • Dr. Brett Gardiner, Director of Clinical Governance & Chief Medical Officer, St. Vincent’s Hospital Sydney
  • Professor Stephen Leeder AO, Editor-In-Chief, Medical Journal of Australia
  • Russell McGowan, Health Care Consumer Advocate & Board Member, Australian Commission for Safety & Quality in Health Care
  • + many more!

For more information, visit

New text on safety and quality in Radiology


A new text on safety and quality in Radiology has just been released.

"Radiological Safety and Quality: Paradigms in Leadership and Innovation", edited by Lawrence Lau and Kwan-Hoong Ng, includes a chapter on incident reporting in radiology by Dr Catherine Mandel and APSF President Prof Bill Runciman. The book is currently available in hardcopy format, and will soon be available as an e-book. More information is available from


New Radiology Events Register (RaER) website


The APSF is excited to announce the launch of a new website for the Radiology Events Register (RaER), a website for reporting medical imaging-related near misses and adverse events. The website has been developed in collaboration with the Royal Australian and New Zealand College of Radiologists, and provides an easier, quicker platform for entering data and receiving immediate feedback about incidents in the database.

The URL for the new website is Reporting is open to all medical imaging staff and interested patients.

Surgical and interventional radiology safety checklist use in Australian hospitals


There is strong research evidence that the use of "time-out" checklists, such as the World Health Organization's Surgical Safety Checklist, improves patient outcomes including surgical site infections and mortality. The Australian Patient Safety Foundation and the Joanna Briggs Institute ( have been funded by the Hospital Contributions Fund (HCF) Medical Research Foundation to conduct a study that investigates the extent of safety checklist use in Australian hospitals. The study follows State Health Ministers' call for implementation of the WHO checklist in Australian hospitals by mid-2011, and support from the Royal Australian and New Zealand College of Radiologists and the Royal Australasian College of Surgeons.

In addition to investigating operating theatres where evidence and support for checklists is strongest, the project will also be conducted in interventional radiology rooms where support is growing. Professor Guy Maddern (RP Jepson Professor of Surgery, University of Adelaide) and Dr Catherine Mandel (Consultant Radiologist, Peter MacCallum Cancer Centre) are advising on these clinical specialties.

The national study will investigate checklist use in clinical practice and policy, what factors affect implementation as facilitators and barriers, how checklists are adapted for local use, and staff perceptions of checklists. The study will address these issues over three phases: a survey phase, an observational and audit phase, and through interviews and focus groups.

The first phase survey of all Australian overnight hospitals was posted to Directors of Surgery and Radiology, and hospital CEOs in mid-May 2013. Please be on the lookout for the survey as a high response rate is crucial to ensuring the validity of the study findings. No identifiers, direct or indirect, will be collected during the survey, and the study has ethics approval from University of Adelaide. Subsequent phases of the study will be conducted later in the year. Please do not hesitate to contact if you have any questions, or to request another copy of the questionnaire.

Evidence, guidelines and practice: the way forward in a digital age


Thanks to all delegates, speakers and facilitators for their contributions to the "Evidence, guidelines and practice" meeting held yesterday in Sydney. In particular, we thank A/Prof Ian Scott, Prof Jeffrey Braithwaite, Prof Ian Olver, Dr Evan Ackermann, Dr Heather Buchan, Prof Chris Baggoley and Dr Helena Williams for giving up their valuable time and leading the discussions and debates.

Copies of the presentations delivered during the day are available for download below:

Timely Access to Emergency Departments


Criterion Conferences are hosting a 2-day conference on "Timely Access to Emergency Departments - Balancing time targets with safe, quality service delivery".

The conference will be held at Bayview Boulevard, Sydney on May 29-30, 2013. The conference will examine issues such as 'What is behind the Emergency Department (ED) bottle neck?' and innovative models for improving waiting times, and access block with an emphasis on safe, quality of care.

APSF Members can receive a $100 discount on registration costs.

The conference website is

2011-12 Annual Report


The APSF's Annual Report for the most recent financial year (2011-12) is now available for download.

Highlights for the year include completion of content development for the WHO's International Classification for Patient Safety, publication of the results of the 'CareTrack Australia' study, HDR completions and continued national and international collaborations.

Click here to download a copy of the Annual Report in pdf format.

Evidence, guidelines and practice: a way forward in a digital age


The Australian Patient Safety Foundation, in conjunction with the School of Psychology, University of South Australia, and the Australian Institute of Health Innovation at University of New South Wales will be holding a one day meeting on Thursday 11th April 2013:

Evidence, guidelines and practice: a way forward in a digital age

at the SMC Conference Centre, 66 Goulburn St, Sydney.

This meeting aims to bring together experts in the development of clinical guidelines, everyday clinicians and researchers to explore the role of evidence and consensus in the development of clinical guidelines and standards.

Speakers and facilitators will include:

  • Professor Bill Runciman, Professor, Patient Safety & Healthcare Human Factors, Centre for Sleep Research, School of Psychology, Social Work & Social Policy - UniSA
  • Professor Ian Olver, CEO Cancer Council Australia, medical oncologist, cancer researcher and bio-ethicist
  • Professor Chris Baggoley, Chief Medical Officer, Department of Health and Ageing
  • A/Professor Ian Scott, Director of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital; A/Professor, UQ, Adjunct A/Professor, Monash University
  • Dr Heather Buchan, Director of Implementation Support, Australian Commission on Safety and Quality in Health Care
  • Dr Helena Williams, Executive Clinical Director, General Practice Network South, Southern Adelaide Local Health Network
  • Professor Jeffrey Braithwaite, Foundation Professor & Director, Australian Institute of Health Innovation, Centre for Clinical Governance Research, Faculty of Medicine, UNSW
  • Dr Evan Ackermann, Chairman, RACGP National Standing Committee - Quality Care 

Download the full program including registration details.

Registration fees are $135 (inc GST) for APSF Members and $150 (inc GST) for non-members. Payment can be made using the PayPal link on the products page, cheque made out to the Australian Patient Safety Foundation or by EFT (full details on the registration form).

Training and Assessment of Non-Technical Skills - Masterclass


During her trip to Australia to present at the Australasian Conference on Error in Medical Imaging (Nov 16-17th 2012), Professor Rhona Flin and APSF Chairman Dr Matthew Thomas will be presenting a masterclass on 'Training and Assessment of Non-Technical Skills'. The masterclass will take place from 0900-1230 on Monday 19th November 2012 at Novotel Manly Pacific, Sydney. The advanced workshop will provide practical guidance for the development of non-technical skills training programs. Shaped around bestpractice in industries such as aviation, healthcare, and mining, this workshop will cover core topics such as ongoing Training Needs Assessment, core knowledge and skill components, as well as training and assessment techniques. It will precede the 10th International Symposium of the Australian Aviation Psychology Association.

Click here for a masterclass flyer.

Australia’s first baseline study of health care standards


Australians receive "appropriate" health care in only 57 per cent of consultations, according the first ever national snapshot of the quality of clinical care in Australia.

The landmark CareTrack study, published in today's Medical Journal of Australia (MJA), found that although there were pockets of excellence in Australian health care delivery there were also shortfalls in treatment for some common conditions and disparities in the standards of care provided by different medical practices.

Research teams from the Australian Patient Safety Foundation, the University of South Australia and the University of NSW spent two years tracking levels of "appropriate care" -- that is care in line with best practice based on the latest medical evidence – in a representative sample of the Australian population.

For some conditions, such as coronary artery disease, patients received very high levels of appropriate care but there was poor compliance with appropriate care standards in some others areas, such as responding to very high blood pressure, administering prophylactic antibiotics at the correct time before surgery, and treating sinusitis.

Discrepancies between healthcare providers were also significant, with some offering appropriate care in 86 per cent of encounters and some in only 32 per cent of encounters.

The study focused on 22 common conditions responsible for over 40 per cent of the total national disease burden.

"Seventeen years after the landmark Quality in Australian Health Care Study, our research provides an opportunity to establish a healthcare baseline from which to move forward, and has identified some gaps in care which should be addressed," says lead researcher at the University of South Australia and President of the Australian Patient Safety Foundation, Professor Bill Runciman.

This is the second study of its kind to be conducted in the world. The first, conducted in the United States 10 years ago, found 55 per cent of US healthcare encounters provided appropriate care.

CareTrack Australia assessed the appropriateness of the healthcare received by 1,150 Australians in 2009 and 2010 in 35,573 healthcare encounters for conditions ranging from coronary heart disease and low back pain, through to stroke, asthma and depression.

Among the study's key findings were:-

· Appropriate care was provided in 57 per cent of healthcare encounters in Australia

· Nearly 90% of patients with sinusitis were prescribed antibiotics, care known to be ineffective

· 18% of patients with asthma had a documented action plan for when they had an attack.

· Less than 30% of patients over 50 had a documented bowel cancer screening test.

· 73% of 50 to 69 year old women had a mammogram every two years

· Almost 90% of people over 18 years old had two yearly blood pressure checks

With health budgets under growing pressure from the ageing population and costly chronic diseases, the study provides a road map for more efficient and cost-effective care delivery.

"Healthcare is likely to become unaffordable unless more appropriate care is provided," said one of the study's Chief Investigators, Professor Jeffrey Braithwaite of the University of NSW.

"To plan for a sustainable healthcare system into the future, it's important to maximise the rate at which patients receive appropriate care so we can address the gaps in care that have been identified."

The study identified a number of barriers to providing appropriate care into the future. Plans to overcome these limitations include a Wikipedia-style collaborative process to develop national clinical standards and tools to guide treatment and to document whether care is appropriate.

The proposed up to date, simple standards can be embedded as tools in both patient and healthcare provider held medical records, paving the way for automatic electronic monitoring and feedback.

The $2 million CareTrack research project was undertaken as one part of an $8.4 million National Health and Medical Research Council program grant, Patient safety; enabling and supporting change for a safer more effective health system, awarded in 2009.

The journal article is available from:

Patient Safety in Radiation Oncology


Save the date - 4-5th October 2012 in Melbourne

A two-day workshop for Radiation Therapists, Physicists & Radiation Oncologists, exploring incident occurrence, detection, prevention and correction. Emphasis is placed on a team based approach, with active participation of national and international delegates through exercises.

For further information please contact or visit


Welcome (back) Anita


APSF recently welcomed back Ms Anita Deakin as a staff member. Anita originally worked at APSF in 1999 before leaving to join the AIMS software developer Patient Safety International (now CSC Solutions) in 2004. Anita brings with her vast experience in patient safety incident classification and ontology development, and we look forward to seeing these skills in action in the coming months.

Website launch for 2012 Australasian Conference on Error in Medical Imaging


The new website for the 2012 Australasian Conference on Error in Medical Imaging was recently launched. The theme for the conference - to be held in Melbourne, Victoria from November 16th-17th 2012 - is the role of human factors in error in medical imaging. Professor Rhona Flin, Professor of Applied Psychology and Director of the Industrial Psychology Research Centre at the University of Aberdeen, will be a keynote speaker. The conference will provide a hands-on approach with workshops on hot topics such as communication, teamwork, health informatics and diagnostic error in medical imaging. For more information, please see the conference website at

APSF Council Update


The Election of Office Bearers to APSF Council was held during the 2011 Annual General Meeting on November 18th .

Professor Jeffrey Braithwaite stepped down as APSF Chairman and is warmly thanked for his years as APSF Chairman (2008-2011). We wish Jeffrey all the best in his ongoing work at the Australian Institute of Health Innovation and Centre for Clinical Governance Research.

Dr Matthew Thomas was elected the new Chairman of APSF. Matthew is Director, Westwood-Thomas Associates and adjunct Associate Professor, Central Queensland University. Formerly Program Director Human Factors and Safety Management Systems at University of South Australia, Matthew completed his PhD in the field of training system design in 2000 and has since specialised in human error, non-technical skills and the design of error tolerant systems, working across high risk industries such as aviation, rail and healthcare. We look forward to working closely with Matthew and all of the APSF Councillors in 2012 and beyond.

Measuring Performance in Hospitals


'Measuring Performance in Hospitals: Using meaningful data to improve the quality of Australian hospital care' will take place on 7-8th September 2011 at the Sebel Albert Park, Melbourne. APSF members receive a 10% discount on the registration costs of the conference and workshops. For more information visit the conference website at

APSF Annual report 2009-10


The 2009-10 Annual Report outlines the key activities and achievements of the Australian Patient Safety Foundation for the financial year ending 2010.

APSF Council Update


The Election of Office Bearers to APSF Council was held during the 2010 Annual General Meeting on December 16th .

Resignations were received from Dr David Tye and Professor Guy Maddern. We would like to thank them both for their many years of service to APSF as Treasurer and Vice-President, respectively.

We would also like to welcome our new Council members: Professor Alan Pearson, Professor Alison Kitson, Dr Neil Jones and Ms Beth McErlean and look forward to working together in 2011.

During the meeting Professor Jeffrey Braithwaite and Professor Bill Runciman were re-elected as Chairman and President, respectively. Dr Sue Johanson was elected as APSF Vice-President.

Error in Medical Imaging - Day 2 conference report


The second day of the conference focussed on interdisciplinary communication as a solution to the problems raised on Day 1. The need for appropriate and documented communication between radiologists and referrers, referrers and radiologists, and radiologists and patients was discussed in detail by Professor Lenny Berlin in his keynote address. Professor Berlin also touched on the patient experience of medical imaging, a theme that was later explored in detail by Ms Stephanie Newell, who recounted her own perspectives of imaging as a consumer.

The theme of communication also prevailed throughout the day, with a range of presentations outlining different approaches including: healthcare teamwork education and training (Dr Stuart Marshall), information communication technology (Dr Tatjana Zrimec), and human factors of communication error and error detection (Dr Matthew Thomas). Proffered papers also included quality improvement initiatives targeting correct patient identification (Ms Joan Howells, Ms Doreen Pawley), the role of radiographers in mammogram screening (Ms Sheila Moran) and descriptive reporting (Associate Professor Tony Smith), the auditing of radiological discrepancies (Dr Howard Galloway) and diagnostic error (Dr Carmel Crock and Dr Neil Jones). Many of the presentations referred to Professor Jeffrey Braithwaite's earlier keynote address on theoretical frameworks for, and lessons learnt from, efforts to re-design healthcare systems. The issue of regulation and accreditation of medical imaging was discussed by Dr Megan Keaney; Dr Nicola Dunbar's presentation focussed on standards applicable in medical imaging. The conference closed with an interdisciplinary panel discussion of 'How to get what you, and patients, need from radiology'.

Powerpoint slides from presentations will be available shortly from the conference website

Error in Medical Imaging - Day 1 conference report


The first day of the Australasian Conference on Error in Medical Imaging was a great success, with good numbers of multi-disciplinary participants from a wide variety of settings. Keynotes Beth Wilson, Bill Runciman and Lenny Berlin set the scene on the first morning from the perspectives of patients, human factors, and diagnostic error, respectively. Other sessions throughout the day included presentations related to information technology's role in medical imaging error, lessons from incident reporting systems and medico-legal claims, and exploration of human factors of people at work. The day closed with a number of presentations illustrating different perspectives of referrers (emergency medicine, general practitioners, surgeons) and medical imaging professionals involved in obtaining and reporting imaging (sonographers, radiographers, medical imaging nurses, radiologists). Discussion centred on issues such as the importance of language (an 'order' compared with a 'request'), the appropriateness and cost-effectiveness of imaging and its relationship to funding, and the potential role of audit in quality control.

The second day is set to be another full day of presentations and discussions, including keynotes from Lenny Berlin and Jeffrey Braithwaite, proffered papers and a closing session titled 'How to get what you need from radiology'. The slides from the Conference will be available for download from the Conference website early next week .

Bondi is proving to be a very popular venue, with the sunshine and warm nights contributing to a relaxed and collegial atmosphere.

Australasian Conference on Error in Medical Imaging


As noted in a recent ABC (Australian Broadcasting Corporation) news article, there is only one month to go until the 'Australasian Conference on Error in Medical Imaging'!

Sponsors, speakers and the program are all finalised and the APSF is looking forward to welcoming a large number of conference delegates to Bondi, Sydney from November 11-12th.

There will be pre-conference workshop on 'The Emergency Department-Medical Imaging interface with a focus on Patient Flow Improvement' on November 10th. For more information on the workshop and conference, please visit the website at:

2010 National Australian Conference on Evidence-based Clinical Leadership


The Joanna Briggs Institute will be hosting the 2010 National Australian Conference on Evidence-based Clinical Leadership in Adelaide 22-23rd November 2010.

The National Australian Conference will focus on the role of evidence-based clinical leadership in improving health and aged care. Evidence-based researchers and reviewers, guideline developers, clinicians, educators, policy makers, administrators and consumers will gather together in front of the big screen to work toward improving techniques and methods of getting evidence into practice.

For more information, visit the Conference website at


Australasian Conference on Error in Medical Imaging


The APSF is very excited to announce that the Australasian Conference on Error in Medical Imaging: Making Imaging Safer will take place in Sydney from 11-12th November 2010.

The Conference will feature international and national speakers defining patient safety problems in Medical Imaging and proposing a way forward to improve the situation.

For more information, visit the Conference website at

APSF Annual Report 2008-09


The Annual Report outlines the activities and achievements of the Australian Patient Safety Foundation for financial year 2008-2009.

Office move


The APSF has recently moved offices and is now based in the Playford Building at University of South Australia, City East Campus.

The move will allow closer ties with the Human Factors and Safety Management Systems group in the Centre for Sleep Research, and other research groups based in the University.

The APSF contact and postal details will remain unchanged, but our physical address is now:

c/o School of Psychology
Level 1 Playford Building
UniSA City East Campus

Radiology Incident Reporting in New Zealand


The Radiology Events Register (RaER) has recently been declared a protected Quality Assurance Activity in New Zealand. This means that diagnostic and interventional radiologists practicing in New Zealand can report an incident into the RaER database and that:

  • any information that becomes known solely as a result of the activity is confidential;
  • any documents brought into existence solely for the purposes of the activity are confidential; and
  • the persons who engage in the activity in good faith are immune from civil liability.

For more information about the Radiology Events Register or to report an incident, please visit

For more information about Quality Assurance Activities in New Zealand, please refer to section 54 of the Health Practitioners Competence Assurance Act 2003, accessible from

PhD Scholarships in Patient Safety


The NH&MRC Patient Safety Program is offering up to ten PhD scholarships

  • Career defining roles in the field of patient safety;
  • University of NSW, University of Sydney and the University of South Australia

Candidates are invited from a variety of academic backgrounds such as but not limited to: sociology, psychology, medicine, informatics, science, public health, computing or pharmacy.

The scholarship provides an annual tax-exempt stipend of $26,669 for three years full time with the possibility of a six month extension and will be awarded on a competitive basis. The scholarships will commence in 2010 or 2011.

Applications must include the following:

· curriculum vitae

· a certified copy of academic transcripts

· proof of citizenship or permanent residency

· the names and contact details of at least two referees

· the names of preferred PhD supervisor and co-supervisor.

More information is available from the Patient Safety Program website: (

Please contact Professor Jeffrey Braithwaite in the first instance for further information.

After discussion, preferred applicants will submit an application for admission to a higher degree research program.

Content development and review for International Classification for Patient Safety


The Australian Patient Safety Foundation (APSF), led by APSF President Professor Bill Runciman, has been engaged by World Health Organisation Patient Safety to develop content for the International Classification for Patient Safety (ICPS).

The project involves populating version 1.1 of the ICPS Conceptual Framework with patient safety classifications and ontological relationships from a diverse group of international sources, including the Advanced Incident Management System. The APSF team will then coordinate the review of this material by international experts.

In the first instance, two types of patient safety healthcare incident types – falls and pressure ulcers – will be included. Subsequent work will examine all incident types included in the ICPS.

More information on the project, including the version 1.1 of the ICPS Conceptual Framework, is available from:

Patient Safety Think Tank


The Australian Patient Safety Foundation and Human Factors and Safety Management System at the University of South Australia are hosting a patient safety Think Tank in Adelaide on March 5-6.

The Think Tank "Humans and Complex Systems: The good, the bad and the ugly" will feature internationally renowned speakers in Patient Safety, Human Factors, Error and Health Informatics.

The program has been designed to provide a catalyst for innovation in the design of error tolerant and resilient systems. The Think Tank will be of interest to researchers, safety and quality personnel, policy makers and clinicians.

Registration forms are available here, and the Think Tank program can be downloaded here. For more information, contact Fiona Dennis (, or visit the Think Tank web page at

Two APSF Council Members Awarded $8.4 Million NHMRC Grant



A major program of research to reduce the number of patients harmed in Australia's hospitals has been awarded $8.4 million in the latest round of National Health and Medical Research Council (NHMRC) grants.

'A million adverse events occur in general practice each year in Australia,' said Professor Jeffrey Braithwaite, one of the project's Chief Investigators and Chairman of the APSF. The team is looking at underlying problems in Australia's health system that harm one in ten hospital patients each year.

The team leaders are internationally recognised for their exceptional leadership in the field of patient safety. They bring together clinical expertise and research and evaluation skills to solve very challenging problems. The team comprises five researchers: Professors Jeffrey Braithwaite, Enrico Coiera, Ric Day (University of New South Wales), Johanna Westbrook (University of Sydney) and Professor Bill Runciman (University of South Australia/ Joanna Briggs Institute and President of the Australian Patient Safety Foundation).

'Overseas data shows that patients receive recommended care only half of the time,' said Professor Braithwaite. 'We will significantly advance this work by investigating how and why this occurs, with a focus on the roles of teamwork, safe medication use and the application of information technology to support improved decision-making.'

Professor Braithwaite, who is Director of the Institute for Health Innovation at UNSW, says there is a lack of evidence about what works in improving patient safety.

'Quality and safety of care are now at the very top of our national health agenda, but everyone is struggling to solve this complex systems problem. We simply cannot afford to keep doing more of the same.'



Source: University of New South Wales press release:

Sidney Sax winner 2008 Professor Bill Runciman


The Australian Healthcare and Hospitals Association (AHHA) is delighted to announce that the winner of the Sidney Sax medal for 2008 is Professor William (Bill) Runciman. 


The AHHA awards the annual Sidney Sax Medal to an individual, active in the health services field, who has made an outstanding contribution in the field of health services policy, organisation, delivery and research.


The AHHA is the peak national body representing public hospitals, area health services, community health centres and public aged care providers.


"Professor Runciman has provided outstanding leadership and made fundamental contributions to patient safety and quality research both in Australia and internationally.  Patients around the world are safer today when they receive health care because of his efforts," Ms Prue Power, Executive Director, said today. 


"Bill was educated in South Africa, studying medicine at the University of the Witwatersrand between 1965 and 1969.  He specialised in Anaesthesia and Intensive Care and received a PhD from Flinders University in 1983. Bill was the Foundation Professor of Anaesthesia and Intensive Care at the University of Adelaide and Head of Department at the Royal Adelaide Hospital from 1988 to 2007


"In 1988, Bill founded the Australian Patient Safety Foundation (APSF) and is still the organisation's President. In 1988, together with APSF colleagues, he conceptualised and implemented the AIMS Incident and Risk Management Program - in the form of a nation-wide paper-based anaesthesia incident monitoring project.  Today, the AIMS incident management software is in use at more than 1000 facilities in Australia, New Zealand, South Africa and the United States.


"Bill has furthered national and international work on patient safety by contributing his expertise on many organisations and committees and has received numerous professional awards.  He has an impressive record of research focused on risk management, patient safety, quality assurance, cost-benefit analysis and resource allocation.  He has been involved in the publication of about 200 scientific papers and chapters, has co-authored a textbook and has given 500 lectures by invitation.


"AHHA congratulates Professor Runciman on this award and his lifetime contribution to improving the safety and quality of health care," Ms Power said.


Professor Runciman of the APSF Appointed to U.S. National Quality Forum Common Formats Experts Panel


Adelaide, South Australia - September 10, 2008 - World renowned patient safety authority Professor William Runciman of the Australian Patient Safety Foundation (APSF) has been invited to serve on the United States National Quality Forum's (NQF) Common Formats Experts Panel. The NQF is a nonprofit organization focused on health care quality measurement and reporting. The panel of 18 experts is tasked with receiving and reviewing comments from stakeholders, and providing input to the U.S. Agency for Healthcare Research and Quality (AHRQ) on the Common Formats designed to facilitate patient safety event reporting in the United States.  

The Common Formats Expert Panel is part of a federal U.S. government effort to improve the safety and quality of healthcare. In 2005 Congress passed the Patient Safety and Quality Improvement Act that created Patient Safety Organizations (PSO) to collect patient safety work product from providers in a standardized manner. The Common Formats version 0.1 beta recently released by AHRQ is designed to facilitate collection and reporting of patient safety information, including adverse events, near misses and unsafe conditions. To inform future updates and revisions AHRQ has contracted with the NQF, via the NQF Common Formats Expert Panel, to gather and analyze stakeholder feedback.

Professor Runciman is a world renowned patient safety pioneer and a highly respected intensive care specialist. He has spent much of the last 25 years researching patient safety problems and developing new approaches and tools to reduce harm in the delivery of care. In addition to being the founding president of the Australian Patient Safety Foundation, Bill is Professor of Patient Safety and Human Factors in Healthcare, at the University of South Australia, Joanna Briggs Institute and Royal Adelaide Hospital. He is a Visiting Professor - Change Management, to the Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales. Bill is a key participant in World Health Organization Patient Safety Alliance projects. He was a co-author of the landmark Quality in Australian Health Care Study published in the Medical Journal of Australia (MJA) in 1995, now the fourth most cited study published in the MJA in the last century. Bill has been involved in the publication of over 200 scientific papers and chapters and has given over 500 lectures by invitation. In 2007, he published the patient safety textbook: Runciman B, Merry A, Walton M, 'Safety and Ethics in Healthcare: a Guide to Getting It Right', Ashgate, Aldershot, 2007.

About the Australian Patient Safety Foundation:
The Australian Patient Safety Foundation Inc. (APSF) is a non-profit independent organization dedicated to the advancement of patient safety. The APSF provides leadership in the reduction of harm to patients in all health care environments.

Australian Patient Safety Foundation
Delia Dent +61 (0)410 575 123

A new addition to APSF staff


APSF welcomes back Natalie Hannaford, from her secondment at the South Australian Department of Health. Natalie works part time at APSF as a Senior Analyst and will be working on a range of AIMS related projects in the coming months.

New staff at the APSF


The APSF recently farewelled Technical Director Peter Hibbert who has moved to the UK to work for the NHS as Associate Director, Clinical Teams, Patient Safety Division, National Patient Safety Agency. Peter's role is to manage clinical teams in the areas of primary care, anaesthesia and surgery, maternity and child health, and mental health with the aim of producing clinically foucssed patient safety advice, reports and guidelines. After four and a half productive years at the APSF, we wish him all the best in this challenging new role.

Peter's position has been taken by Dr Tim Schultz, who will continue to work for the Joanna Briggs Institute on a part-time basis.

APSF Annual Report 2006-2007


The Australian Patient Safety Foundation's Annual Report outlines the resources produced, presentations and papers given and projects undertaken for the financial year 2006-2007.

The Collaborations for Translating Evidence into Practice (CTEP) Program


The inaugural meeting of the “Collaborations for Translating Evidence into Practice” (CTEP) was held at Coogee on June 21-22, 2007. The meeting was attended by 30 influential leaders in health care to discuss proposals to establish clinician led reform of the health system.

The presenters were:

Professor Bill Runciman: An Overview of the problem - an international perspective and Setting priorities: evidence from the USA, UK and Australia

Ian Scott: An Australian perspective

Jeffrey Braithwaite: Evidence for translating evidence into practice

Dr Mike Stein: The Map of Medicine

Professor Alan Pearson: Nursing and aged care guidelines

Dr Annette Pantle: An Australian story

Professor Bruce Barraclough: Issues with surgery

Professor Alan Wolff: Issues with general practice

Professor Cliff Hughes: Issues with medication management

Professor Heather Gibb: Issues with nursing and aged care

A Coogee Charter was agreed by the meeting delegates:

“The aim is to improve safety and quality of healthcare through clinician-led collaborations by setting and implementing national clinical standards to translate evidence into clinical practice and show measurable improvement by 2010.”

This will be done by setting up a series of Collaboratives that are based on specific problems. An open invitation to participate be issued to all with an interest in that area.

The meeting was organised by the Joanna Briggs Institute, the Australian Patient Safety Foundation, the Centre for Clinical Governance Research in Health and kindly hosted by the Centre for Health Informatics at the University of New South Wales. The organisers would like to thank the Western Australian Department of Health, the South Australian Department of Health, The Victorian Department of Human Services and Queensland Health for their financial support.

Full meeting summary and proposed way forward.

The APSF Annual Report 2005-06


The Australian Patient Safety Foundation's Annual Report outlines the resources produced, presentations and papers given and projects undertaken for the financial year 2005-2006 .

APSF's Anaesthesia Crisis Management Manual Second Edition (2006)


Download Order Form

Following upon the original 1996 publication of the 1st Edition of APSF's unique, data based collection of anaesthesia crisis management protocols based upon the first 2000 AIMS Anaesthesia incident reports, APSF is pleased to announce the release of the 2nd Edition of this Manual in November 2006.

This 2nd Edition is based upon the first 4000 AIMS Anaesthesia voluntary and anonymous incident reports submitted to APSF from practising anaesthetists in Australia and New Zealand. It contains stepwise protocols for the clinical management of 28 of the most commonly encountered acute clinical situations in anaesthesia practice (including paediatric anaesthesia). Special Appendices deal with adrenaline (and some other) critical dosage calculations and preparations.

The protocols have been 'internally validated' against those incident reports relating to each respective crisis where the management and/or outcome were identified as sub-optimal. Rapid access to each protocol is facilitated by attachable adhesive finger tabs. A web-based version of the protocols can be found here.

Requests for copies of this 2nd Edition, at a cost of Aus$20.00 (+ GST within Australia only) and plus postage for overseas orders only, are available by phone, fax, email or mail, via the following contacts:

Australian Patient Safety Foundation

GPO Box 400


South Australia 5001

Phone 61 (0)8 8222 5115

Fax: 61 (0)8 8232 6938


Download Order Form

International Patient Safety Event Classification Stakeholder Consultation


The World Health Organisation's World Alliance for Patient Safety is embarking upon a consultation process (the "Delphi survey") for the International Patient Safety Event Classification (IPSEC). This process is designed to obtain vitally important feedback on the proposed conceptual framework, concepts and terms.

Practitioners and other experts interested in patient safety are invited to participate in the Delphi survey to ensure we obtain wide-ranging input.  Your participation is greatly valued and appreciated.

As a result of the feedback received through the Delphi Survey, the
IPSEC will be further revised.  Field testing will commence in 2007. It is envisioned that the finalised version of the IPSEC will be available in 2008.

To access the Delphi survey visit:

WHO's Patient Safety Home Page can be accessed at:

APSF Summit 2006: From Understanding to Improvement


The APSF 2006 Summit was held on:

Wednesday, 11 October 2006 at

Brookman Hall, University of South Australia

Speakers and Presentations:

Comparing the First and Last 2,000 Anaesthetic Incidents using AIMS


The APSF receives anonymous paper-based incident reports from anaesthetists in Australia and New Zealand - the APSF has over 8,000 of these reports classfied and another 2,000 waiting classification.  The Australian and New Zealand College of Anaesthetists has provided the APSF with a grant to "Compare the latest 2,000 incidents with the first 2,000 to track progress and devise safety strategies for new problems".

The last 2,000 incidents received by the APSF will be classified into the Advanced Incident Management System (AIMS). The types of clinical situations, their circumstances, contributing factors, minimising factors, monitors used, and outcomes will be compared to the first 2,000 incidents. The 30 articles published in the 1993 Anaesthesia and Intensive Care Symposium will be used as the basis of the comparison.

The project commenced in January 2006 and is expected to be completed by the end of the year.

Development of an Conceptual Framework for an International Patient Safety Classification


The World Health Organisation's Alliance for Patient Safety has asked the APSF to lead the Working Group to develop the Conceptual Framework for an International Patient Safety Classfication. The Working Group will develop and define the high level concepts to ensure that the Classification

complies with the specifications required of all WHO Family of International Classifications.

Other members of the Workgroup include Thomas Perneger, Tjerk van der Schaaf, Richard Thomson, and JCAHO.

WHO has commissioned another group to identify a list of critical concepts to be included in the classification.

APSF Summit 2005: Innovations in Patient Safety for Clinical Leaders


Aim: To present the latest information so you can implement quality and safety changes at your department or unit.

Wednesday May 18th 2005

Robson Lecture Theatre, Royal Adelaide Hospital

The APSF Summit was held in association with the South Australian Department of Health, the Royal Adelaide Hospital and the University of Adelaide.

The title of the Summit was Innovations in Patient Safety for Clinical Leaders. The Summit recognized that changes in patient safety are very difficult to make and sustain at the interface between clinician and patient. The aim of this Summit was to give clinicians practical ways to implement initiatives at departmental and ward level and to convert existing research into positive change.

The APSF would like to acknowledge the Australian Council of Safety and Quality in HealthCare, for providing support and for inviting Professor Cliff Hughes OAM.

Links to presentations are provided below:

Qualified Privilege / Statutory Immunity


The Australian Incident Monitoring System (AIMS) was declared a Quality Assurance Activity in June 2001 by the Commonwealth Health Minister under Part VC of Section 124X of the Health Insurance Act 1973. The declaration is valid until June 2006. Protection under this legislation is intended to protect:

  • The confidentiality of information that identifies information that becomes known solely as a result of the quality assurance activity; and
  • people who participate in activities that involve the assessment or evaluation of the quality of health services provided by others.

The APSF is currently consulting with the Australian states and territories to consider the re-declaration of AIMS, and to ensure that all stakeholder's requirements are met.

Root Cause Analysis in Residential Aged Care


The Quality Outcomes Branch of the Australian Department of Health and Ageing has appointed the Australian Patient Safety Foundation to undertake the Developing the Use of Root Cause Analysis in Residential Aged Care Project.

The aims of the project are to develop a resource that will:

  • Identify and define adverse and sentinel events in the residential aged care context;
  • Identify when RCA should be used in residential aged care;
  • Increase focus on the clinical safety of residents in a residential aged care setting;
  • Develop a tool kit on RCA in plain English that is easy to read and apply in residential aged care, to assist staff with the investigation and identification of processes that may be contributing to adverse health outcomes; and
  • Identify training needs to implement RCA in residential aged care.

10 Tips for Better and Safer Care in Residential Aged Care


The Quality Outcomes Branch of the Australian Department of Health and Ageing has contracted the APSF to produce a booklet "10 Tips Guide for Safer and Better Residential Aged Care." This builds on the work of the Australian Council for Safety and Quality in Health Care - in 2003, they produced a booklet titled "10 Tips for Safer Health Care".

The current project aims to adapt and broaden this publication for the aged care setting. It also aims to empower residents and their families by providing quality and easy to understand information on safer living in residential aged care facilities.

Currently, the draft Guide is subject to usability trials with consumer and carer groups.