Learning from harm

Opportunities to learn and improve care across NSW Health.

Latest publications

Paediatric presentations, child wellbeing and child protection

Key lessons from PARVAN serious incident reviews to strengthen child and family safety.

October 2026

Prevention and Response to Violence Abuse and Neglect

Insulin

Common issues associated with insulin prescribing, administration and monitoring.

October 2026

Clinical Management

Perinatal mortality review

A look at how contributory factors can inform learning and system improvement.

September 2026

Maternity and Neonatal

Learning summary: February to March 2026

Quarterly summary covering care planning, PACER response and engaging with family and carers.

September 2026

Mental Health Alcohol and Other Drugs

Collaborative care for mental health, alcohol and other drug comorbidity

Key lessons for collaborative care of consumers with MHAOD and physical health comorbidities.

August 2026

Mental Health Alcohol and Other Drugs

Escalating care when observations remain in the white zone

Learnings on escalating red flags, family and clinician concern and prompting early senior involvement even when the child's vital signs remain within the Between the Flags white zone.

July 2026

Children and Young Persons

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Care settings

Subcommittees

Serious incidents provide valuable opportunities to learn and improve care across NSW Health. Reviewing these incidents helps health services identify how to reduce harm and improve patient outcomes.

This collection of learning from harm publications shares lessons, case insights and emerging trends from serious incident reviews to support learning, improvement and safer care across the health system.

The publications are informed by analysis undertaken by 6 serious incident review subcommittees.