Safer Care Victoria

Healthcare patients and their families/carers who have been impacted by serious adverse patient safety events (SAPSE) are entitled to play a role in internal review processes that seek to understand how their harm occurred. By involving impacted consumers in adverse event reviews, a fuller understanding of contributing factors can be gained, which leads to more accurate and robust findings, and better system improvements. 

Resources

In partnership with health services and consumers, we have developed a set of resources that can be used during the review process.

Sometimes things go wrong in healthcare, which can result in a patient being harmed. In these cases it’s important for the health service to:

• understand what happened
• understand how it happened
• make recommendations to reduce the chance it will happen again.

Learning from these events is a powerful tool to prevent harm going forward.

This page provides information on Safer Care Victoria’s role and the actions health services take when things have gone seriously wrong with patient care.

Our Just Culture resources support health services to strengthen their safety culture and improve patient experiences and outcomes.

What is Just Culture?

Just Culture is part of a safety culture that applies a systems perspective when developing organisational processes, including the review of adverse patient safety events. It enables a workplace where employees feel safe to report adverse patient safety events. It promotes the concept of shared accountability between the organisation and the people in the system, supporting a fair (‘just’) approach.

The Safewards model and associated interventions identify the causes of behaviours in staff and consumers that may result in harm - such as violence, self-harm or absconding - and reduce the likelihood of this occurring. Independent evaluations of three trials of Safewards within Victoria, across three different healthcare settings, demonstrate that Safewards can be effective at reducing conflict where mental health consumers require care.