The release of “Targeting Zero: Report of the Review of Hospital Safety and Quality Assurance in Victoria”1 in October 2016 seemed a long time coming – but it was well worth the wait. From my perspective, it’s a racy page turner: a good hard look at Victoria’s clinical governance gaps and how to close them, which will be useful for anyone seeking to provide safer, better care. It is fantastic to see authentic safety and quality issues being named and explored, with associated recommendations for real change; exciting to see leadership and culture recognised as key to that change, at both state and health service levels; a relief that out of such tragedy at the Djerriwarrh Health Services comes an honest appraisal of system gaps and clear direction for improvement.
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