Introduction: Breaches in patient safety and quality are often caused by the increasing complexity of patients, interventions, medical devices, and medications, as well as inadequate communication. When care is compromised, a robust investigation of complaints and incidents must be conducted, which also ensures the psychological safety of staff. Aim: To outline processes to investigate complaints and incidents, support staff, and generate lessons learned. Findings: The Human Factors framework is a lens for exploring patient safety and quality. Understanding the interaction between people, management, and workplace elements within a complex healthcare system is important. Statewide complaints and incident policies are based on human factors, systems thinking, and just culture, with a clear outline of how health services must investigate and report. For serious incidents, the policy outlines the requirement for a Preliminary Risk Assessment, open disclosure, patient/carer/family support via a Dedicated Family Contact, addressing concerns about staff welfare and conduct, incident notification and escalation via a Reportable Incident Brief. Media interest, statewide risks, and external notifications are taken into consideration. There are four incident review methodologies available for the Serious Adverse Event Review Team: Root Cause Analysis, London Protocol, Concise and Comprehensive incident analysis. Following their investigation there is feedback to the ministry, patients/families and staff, oversight for recommendations by local governance committees, and tabling at the state-wide Clinical Risk Action Group. Conclusions: Psychological safety and a culture for reporting and investigating complaints and incidents are a priority for healthcare organisations. Investigations should provide recommendations to improve practice and communication. The system is considered in terms of how clinicians work, why complaints or incidents occur, and the design of a better system for working.