Applying Critical Systems Analysis to Serious Incidents in Aged Care

Mr Pete  Williams;  BNursing, MEd (Honours), GradCertAgeing, GradCert Ed, MACN1

1OneCare Limited, Hobart, Australia



OneCare Limited is the second largest aged care provider in Tasmania and has implemented a process called Critical Systems Analysis (CSA) enabling aged care services to critically analyse serious incidents to better understand causation and implement improvements in process and systems that reduce future harm to those receiving care.


As the first clinical CEO in OneCare’s history and co-designer of the CSA, the tool was created using internationally recognised incident review methodologies associated with Root Cause Analysis (RCA) and the Human Error and Patient Safety (HEAPS) principles.   Whilst the RCA and HEAPS processes provide a way to analysis serious incidents in the acute healthcare setting, the aged care sector required a less resource intensive process that could be applied to both complex and lower level incidents.  In 2021, this process was introduced into OneCare Limited to assist nurses to critically review incidents and to identify causation of incidents, facilitate clinical education and use the information gained to change processes, apply open disclosure and provide a level of transparency needed in our industry.


Over the past six months, eight CSA’s have been completed across OneCare Limited.   The CSA reviews explored themes around unexpected death, unactioned clinical deterioration and fracture following a fall.  The main contributing factors identified included; staff knowledge and education, communication break down and gaps in clinical information.  Improvements focused on education and training, collaboration with GP’s and improved processes to identify and manage deterioration.


Pete is Registered nurse and currently the CEO for OneCare Limited. He has worked in the health care industry since 1994 and has a deep connection with the philosophy of servant leadership.

Pete’s has worked across many sectors of health from public to private, metropolitan and regional, community services and now aged care.  He has held state and national roles with a strong focus on Clinical Governance, education, quality and risk management systems.  He has published journal articles specifically in health and aged care and has been presented at several Australian healthcare conferences on systems analysis, accreditation preparation and leadership