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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. 

SCV partnered with health services to pilot the Falls Review Tool. Participating health services provided valuable feedback during the pilot to improve the tool and user guide. The Falls Review Tool is now available for health services to use, accompanied by a user guide, which also contains instructions on how to use the tool for a sentinel event. 

The Falls Review Tool has been designed to assist health services to:

  • understand their current state in relation to falls prevention 
  • streamline the review process 
  • use a human factors (systems thinking) approach to serious falls incident reviews 
  • strengthen recommendations resulting from falls reviews.  

Please note:

  • For a trial period commencing 1 November 2022, falls directly causing serious harm or death did not require notification as a sentinel event.
  • Following consultation with a Sentinel Event Program advisory committee, this guidance was revised.
  • From 27 February 2024, health services will again notify sentinel events (with revised criteria) related to falls.
  • Health services are encouraged to familiarise themselves with the updated sentinel event guidance relating to falls.

More information

Sentinel Event notifications and falls


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