WSLHD Lessons Learned

Western Sydney Local Health District

Lessons Learned

The Western Sydney Local Health District is committed to providing the best care we can, but we also recognise that sometimes the treatment and care we provide does not meet our patients expectations, or indeed our own expectations.

We acknowledge that any incident resulting in harm to a patient is unacceptable and all such incidents must be reviewed to learn what we can to prevent a similar incident recurring.

The NSW Patient Safety and Clinical Quality Program is embedded in the services of our  District and provides guidance and support  to staff to report errors that might create a safety risk to patients. Incident trends and outcomes of investigations are provided to clinical and management teams, who play a part in changing practice to improve care.

We continue to work closely with NSW Clinical Excellence Commission (CEC) which is responsible for taking a wider look at trends in patient safety and ensuring how lessons learned from incidents can be communicated across NSW.

Our Board is committed to knowing about and attempting to learn from adverse incidents in the care of patients and has requested the lessons learned from investigations be published on this Lessons Learned website to: share the experience of the incident, to share the proven solutions and to improve our understanding of how errors can be prevented in the future.  The District Health Care Quality Committee is overseeing this process in consultation with the Board and management.

If you have comments or questions about the lessons learned published on this site, please contact

Latest Lessons Learned

7 Jul 2016 Improved Communication with Family and Carers
A 56-year-old man who had a disabling brain injury and epilepsy since birth was brought to hospital in the middle of the night for treatment of vomiting and pneumonia.
7 Jul 2016 Improvements Made to Ensure Safer Transfer of Care
A middle aged man arrived by ambulance to the Emergency Department after a fall in the Nursing home where he lived.
4 Mar 2016 Changed Processes after a Focus on Trauma Misses Infection
A man came into ED with injuries to many parts of his body. He was experiencing pain and coughing up blood. Later analysis of the case determined that staff focused on the man's trauma symptoms and had not appreciated his total clinical picture.
4 Mar 2016 Changes Result from Medication Missed
After her heart operation, a patient was not given a medication that should normally be given.
26 Sep 2014 Changes to Clinical Management in ICU
Ventilated patient in ICU was found disconected from ventilator. Large glass windows fitted to doors, ventilator & monitor alarmed & regular audits performed.
18 Jul 2014 Revised Protocols following a Patient Death
After a prostate operation, a patient was feeling unwell. Further investigation revealed Deep vein thrombosis (DVT) resulting in blood clots in both lungs
9 May 2014 Simple Changes to Ensure Safety in Surgery
Surgery commenced on the wrong finger. Marking procedures were reviewed, education has been given and audits strengthened.
9 May 2014 The Right Milk for the Right Baby
A nurse gave the wrong expressed breast milk to a baby, who was not harmed by the error. Procedures have now been simplified.
9 May 2014 Keeping Mental Health Patients Safer by Improving Systems
A mental health patient suicided whilst on temporary leave from hospital. Family and community support teams are now more involved when planning leave.