Working towards the elimination of restrictive practices in inpatient services
Elimination of restrictive practices
The MHIP partners with clinical and non-clinical workforce teams to design and test improvements that:
Albury Wodonga Region Colonoscopy Recall
In 2022-23, Safer Care Victoria worked with Albury Wodonga Health, Albury Wodonga Private Hospital and Insight Private Hospital to contact around 2,000 patients who had a colonoscopy performed in the region since 1 January 2018.
An investigation had found that some colonoscopies performed in the region were incomplete, which may have affected the accuracy of the resulting diagnoses.
Many affected patients underwent a repeat colonoscopy as a precautionary measure.
Duty of Candour resources for patients, families and their carers
The Duty of candour is a new legislative requirement for Victorian health services, which came into effect on 30 November 2022.
The Duty of candour builds on existing elements of open disclosure as outlined in the Australian Open Disclosure Framework and encourages open, honest communication when a patient has suffered a serious adverse patient safety event while receiving care.
What are adverse and sentinel events?
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.
Posted on 03 Nov 2022
Alert: Flow control tubing for mechanical infusion pump
Safer Care Victoria was recently notified of 5 adverse events where incorrect tubing had been connected to a mechanical infusion pump, resulting in an anaesthetic agent being administered at a higher rate than intended.
Poor design of tube labelling and lack of other system-based safety guards likely contributed to these adverse events.