Safer Care Victoria

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. 

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.

Where COVID-19 is acquired within a healthcare setting that results in serious harm or death of a patient, the incident should be reviewed internally using the Rapid adverse event review tool – COVID-19 related deaths occurring in health services. 

If a health service identifies a cluster of events (more than one), it is recommended they contact the sentinel event program to discuss.

Falls remain a serious threat to patients in the health system. In 2019-20, there were 25 sentinel events reported to Safer Care Victoria (SCV) that were directly attributed to falls. We’re committed to improving outcomes from falls adverse event reviews. 

The Health Legislation Amendment (Quality and Safety) Act 2022 introduced new reforms and amended the Health Services Act 1988, the Ambulance Services Act 1986, the Mental Health Act 2014, the Public Health and Wellbeing Act 2008, and the Health Complaints Act 2016. The following provisions came into effect on 30 November 2022.