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Sentinel events are the most serious adverse patient safety events in our healthcare system. And it’s important that we all learn from them.

That’s why we release this report every year – to share what we have learnt and to help health services prevent similar events.

Even when our healthcare system faces extraordinary challenges, 2020–21 demonstrated continued commitment by our health services to recognise, review and respond to adverse patient safety events.

Between July 2020 and June 2021:

  • 168 sentinel events were reported to us
  • 45 per cent of sentinel event reports included input from the affected consumer or their family member. This is a considerable improvement from 35 per cent in 2019-20
  • 1041 recommendations for improvement were developed from the review of sentinel events.

Read our report for more insights, recommendations and examples of health services leading the way in preventing patient harm.

What’s new?

This year, we focused on three sentinel event themes:

  • mental health
  • residential aged care
  • the impact of COVID-19 in healthcare settings. 

Read past reports

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