Open Book: Learning Review (March 2021)
The Health Quality & Safety Commission’s (the Commission’s) National Adverse Events Reporting Policy 2017 supports health and disability service providers to use various review methodologies.
This Open Book introduces the Learning Review, a process originally developed in the United States Forest Service. It takes a systemic approach to developing a learning culture and improving organisational resilience, and shifts the focus of the review process from causation to prevention.
This report is relevant to all staff and team members who manage adverse event reviews.