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.
Our Just Culture resources support health services to strengthen their safety culture and improve patient experiences and outcomes.
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.
David Watters has been appointed to the role of Director of Surgery at SCV to lead the Perioperative Learning Health Network within the Centre of Clinical Excellence.
He is committed to improving perioperative care before, during and after surgery and working with all the disciplines involved across the whole patient journey. He was Chair of the inaugural Victorian Perioperative Consultative Council (2019-2022) and will continue to support the VPCC in his new role.
Understanding your organisational readiness for change and strengthening the capability in quality improvement and consumer partnership in all areas of your health service will deliver more successful improvement work.
These tools can help you measure your organisational readiness.
At Safer Care Victoria we use the Model for Improvement, developed by the Associates for Process Improvement, as the framework for our improvement work. Guided by simple but effective improvement science principles, the Model for Improvement helps us deliver results-based outcomes and support improvement in healthcare.