Moving forward in patient safety from 2 sentinel events in the little town of Nhulunbuy.

Mrs Karen Hart1, Ms Chloe Lyons1
1Top End Health Service, Nhulunbuy, Australia

Patient safety is the critical factor to all our workplaces but the fundamental key is what we learn from our errors and how we move forward in improving patient safety.  Over 18000 deaths in the Australian health care sector can be attributed to medical error (WHO Patient Safety Curriculum guide: multi professional edition, 2011).    Generally when these adverse outcomes happen – the public want someone accountable, that the person made a choice and should have known better.  However it is suggested that we look forward to a culture where finger pointing is not routine and the light is shone on systems, programs, education, equipment design or organisational features (WHO Patient Safety Curriculum guide: multi professional edition, 2011).  In Gove we are a small hospital that deals with many issues such as remoteness, staff recruitment and retention, small teams and the list goes on.  We have 5 beds in our emergency department which includes 2 resus beds and 3 “cubicles”.  But we have come a long way in the past 5 years that lends itself to patient safety – especially when you have had 2 coroners’ cases within the space of 6 months!  Sadly the death of a first time young mother was closely followed by the death of a 12 year old girl.  What went wrong?  Our process, our systems or was it human error?  Without finger pointing, the coroner gave advice and since these events we have developed from essentially a clinic, working from CARPA to a fully-fledged emergency department with a FACEM now in the team.  What did we learn?  What have we changed and where are we headed are the questions burning in everyone’ mind about the amazing little town of Nhulunbuy.


  1. Karen Hart has been nursing for 17 years. Previously worked in theatres and then moved into emergency nursing 12 years ago. Holding a Graduate Diploma in Emergency Nursing and a Masters in Nursing, worked as a course co-ordinator of the Post Graduate Emergency Certificate at the University of Tasmania. Some family travel and  brief work in Alice Springs Emergency, then brought me to work in Gove in the ED.  I have since become the clinical nurse manager and working well with the amazing team to implement a lot of change.
  2. Chloe Lyons, originally from Cohuna in Victoria, and nursing in Emergency since 2009.At Bendigo Base Hospital Chloe worked in both the ED as CNS and also ICU. A short stint in Melbourne city ICU and ED’s saw her return to Bendigo and work as an ANUM. A Diploma in critical care with an education focus and currently working towards her masters, Chloe has been teaching under and post graduate nursing at LaTrobe University for the past 5 years.  With a passion for simulation and education and at Gove District Hospital as the Clinical Nurse Educator, she recently delivered the first ALS2 course at Gove as an ALS2 instructor.