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This guide has been revised to help health services in Victoria fulfil their obligations when notifying and managing sentinel events.

In Victoria, the term ‘sentinel event’ refers to an “unexpected and adverse event that occurs infrequently in a health service entity and results in the death of, or serious physical or psychological injury [category 11 only] to a patient as a result of system and process deficiencies at the health service entity”.

Victorian health services must notify and review sentinel events that meet the criteria for both the Australian sentinel event (ASE) categories (1-10) and those that fall under the Victorian-only category 11.

The Victorian sentinel event guide (Version 2) is a supplement to information included in ASE resources. It includes guidance on the Victoria-only sentinel event category 11 and the statutory duty of candour.

What do health services need to do:

  • Following consultation with a Sentinel Event Program advisory committee, health services will again be required to notify sentinel events (with revised criteria) related to falls and all healthcare associated infections.
  • Familiarise yourselves with the updated guidance regarding notifiable sentinel events. For example, psychological harm, falls, self-harm and healthcare associated infection.
  • Review the differences between sentinel event categories 1-10 and category 11.
  • Revise the requirements for completing a sentinel event review.

We've also developed an updated poster for you to display in your health service to ensure staff are familiar with the 11 sentinel event categories.

For more information, see sentinel events or contact

Get in touch

Sentinel event program
Safer Care Victoria
1300 543 916
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