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    This report provides the Victorian community and the health sector with information on the most serious adverse events reported in Victorian public and private hospitals, and ambulance services.

    Sentinel events are the most serious adverse patient safety events in our healthcare system. 

    Victorian public and private health services notified 186 sentinel events in 2019–20 – the highest number since the program began. 

    This demonstrates a growing commitment by our health services to recognise, review and respond to adverse patient safety events. 

    Read our annual report to find out more about key review insights, recommendations and examples of health services leading the way in preventing patient harm.

    What’s new?

    This year, we focus on the three most frequently reported sentinel events issues: 

    • pregnancy, labour and the post-natal period
    • patient falls 
    • medication errors. 

    We have also shared the root causes of these incidents, as identified through root cause analysis reviews.

    Read past reports

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