In a healthcare system ranked among the world’s best, Australia continues to deliver strong outcomes for the majority of patients. Yet patient safety incidents — and the investigations that follow — remind us that excellence is not immunity. How we manage, learn from, and prevent adverse events is critical to ensuring every patient’s journey is as safe as possible.
At the Connected Health and Care Summit 2025, two thought leaders — Professor Peter Hibbert and Dr. Darren Kilroy — challenged us to rethink the foundations of incident management, governance, and patient safety. Their insights offer a roadmap for building safer systems through both technological advancement and cultural transformation.
Strong Systems Still Need Stronger Investigations
Professor Peter Hibbert opened with a reminder: while Australia’s healthcare outcomes are globally recognised, approximately 10% of hospital admissions still experience an adverse event. Traditional investigations focus heavily on documenting what went wrong — often missing the deeper, systemic factors that explain why.
“The investigation is a diagnostic process. But unless we invest equally in implementing quality improvement, it’s like diagnosing a disease but never treating it.” – Prof. Peter Hibbert
His research across multiple jurisdictions revealed that:
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Burnout is common among safety and quality staff, overwhelmed by growing investigative workloads.
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Learning is often deprioritised — many investigations focus on severity rather than learning potential.
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Recommendations are fragile, often not tested, trialled, or sustained beyond the final report.
Moreover, Hibbert’s research pointed to a major opportunity: using AI and large language models to mine patterns and emerging trends from the hundreds of thousands of incidents reported every year — allowing earlier interventions and smarter system responses.
Moving Beyond the Investigation to Meaningful Action
One of the most striking insights was that while incident investigation models are well-developed, the implementation of change remains inconsistent.
Professor Hibbert proposed an important shift:
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Investigations should be prioritised not just on severity, but also on potential for learning and systems improvement.
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Recommendations should initially be treated as hypotheses — ideas to be tested and refined in practice.
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System-level risks (such as medication errors with look-alike drugs) must be aggregated and addressed nationally, not left to individual health services.
This approach demands a broader, more strategic view of risk, moving beyond reactive investigation towards proactive system redesign.
Language, Culture, and the “Healthcare Canary”
Dr. Darren Kilroy took the conversation further — from systems to culture. His talk, “It’s Not Just What You Say, But How You Say It,” explored the critical role of language and behaviour in early risk detection.
Drawing on the metaphor of the “canary in the coal mine,” Dr. Kilroy urged healthcare leaders to trust their instincts and sharpen their professional curiosity.
“Incivility costs lives.” – Dr. Darren Kilroy
Key lessons:
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Early warning signs are often subtle: changes in tone, body language, whispered frustrations, or shifts in morale.
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Sentinel words — such as “shouted,” “ignored,” “isolated” — can reveal the first cracks in team dynamics and patient safety.
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Professional curiosity — observing, correlating, and acting on these signs — is as important as formal reporting systems.
His message was clear: while technology like incident reporting platforms and AI enhances our capability, human insight remains irreplaceable. By combining objective data with subjective human signals, organisations can detect and prevent harm before it escalates.
The Path Forward: Technology, Culture, and Courage
Both speakers agreed: software and reporting systems are vital, but they are not solutions in themselves. True safety improvement demands a cultural shift — a willingness to observe, listen, challenge, and act.
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Technology should make risk visible and actionable.
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Culture should empower every healthcare worker to raise concerns, regardless of hierarchy.
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Courage is needed to escalate subtle risks before they become serious harm.
By uniting systematic investigation with professional vigilance, and strengthening the links between reporting and action, healthcare organisations can move from simply identifying harm to systematically preventing it.
Final Thought
“Saving lives doesn’t always start with a code blue. It often starts with a conversation, a word, a feeling that something isn’t right — and the courage to act.”
What’s Next?
Check out our On-Demand Hub!
Our On-Demand Hub brings you all the sessions covered during the Summit so you can re-watch them or watch it for the first time; including speaker presentation decks.
If you’re interested in learning more about RLDatix’s solutions and how we’re transforming governance, risk, compliance, and workforce management in healthcare, check out our website and get in touch with us.
