In response to adverse media coverage relating to the provision of services at a health service entity in Queensland, the Health Ombudsman opened a proactive activity to evaluate the entity’s management and reporting of incident reviews and associated recommendations.

Wider learnings and recommendations for service improvements

The proactive activity highlights the opportunity for health services to:

1. Review recommendations from clinical incident analyses to:
   1. identify common themes arising; and
   2. evaluate progress towards implementation of recommendations.
2. Review the organisation’s action plans to ensure they are dated, adequately identify the ongoing/completed actions and person/s responsible.
3. Review the organisation’s Safety and Quality Plan to ensure it is aligned to the themes, recommendations and findings from incident analyses.
4. Ensure there are clear processes in place to facilitate the timely provision of Root Cause Analysis reports to the Health Ombudsman.