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.
How do health services report when things go wrong?
When patients have been harmed during their health care, health services record these events in their incident management system. Experienced staff then look at what happened and why. If a patient has died or experienced serious harm that was likely related to the care provided, the health service may be required to report this adverse event to SCV as a sentinel event. Sentinel events are reported in each Australian state and territory. In Victoria, SCV oversees the reporting of sentinel events.
What is a sentinel event?
A sentinel event is when something goes wrong with a patient’s care that causes them serious harm or death that could have been prevented. Serious harm means that, because their care went wrong, the patient:
- needed life-saving surgical or medical care that they would not have needed if their care had gone well
- won’t live as long as they would have if their care had gone well
- has experienced harm or lost the ability to do things, and that these problems will be long-term.
For an incident to be classified as a sentinel event, it needs to meet one of the following criteria:
- Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death (an invasive procedure is defined as a medical procedure that enters the body, usually by cutting or puncturing the skin or by inserting a needle, tube, device or scope into the body)
- Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death
- Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death
- Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death
- Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death
- Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward
- Medication error resulting in serious harm or death
- Use of physical or mechanical restraint resulting in serious harm or death
- Discharge or release of an infant or child to an unauthorised person
- Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death
- All other adverse patient safety events resulting in serious harm or death.
Who must report sentinel events to SCV?
The following health services must notify sentinel events to SCV:
- public health services
- public hospitals
- multi-purpose services (a multi-purpose service provides integrated health and aged care services for senior Australians living in small communities in regional and remote areas)
- denominational (religious) hospitals
- private hospitals
- day procedure centres
- ambulance services (within the meaning of the Ambulance Services Act 1986)
- non-emergency patient transport services
- a registered and licenced First Aid Service
- Victorian Institute of Forensic Mental Health.
Sentinel event review process
When health services review a sentinel event, they follow a process that helps them understand what went wrong, how and why. This is done by a group of experts, including an expert who does not work for the health service, and a person representing the patient’s and family’s perspective (consumer representative). They will write a report, which will include plans (recommendations) to reduce the chance of something similar happening to someone else.
The people conducting the review should give the patient and/or their family/carers a chance to share their story, concerns and questions, and include these in the review process. Patients and families/carers can choose whether to contribute to the process or not. They can also choose how they would like to provide their information, e.g. in a conversation or in writing.
After the review, the health service should provide the patient and their family/carers the chance to meet with the health service to discuss what the review found, and what changes will be made to make care safer. The patient and their family/carer should be offered a copy of the report of the sentinel event review. If a meeting in-person is not practical, these conversations might happen over the phone, with written information provided by email or mailed out to home addresses.
I’ve experienced a serious and tragic event, why isn’t this a sentinel event?
For an adverse event to be reported as a sentinel event, it needs to meet clear criteria. Only a small percentage of deaths or poor outcomes that occur in a health service need to be notified as a sentinel event. A sentinel event review is only one of many ways a health service might review a death or a poor outcome.
When an adverse patient safety event does not meet sentinel event criteria, the health service may still be expected to conduct a comprehensive review. This review should include the opportunity for the patient and/or their family/carers to contribute and then be informed of findings and actions to follow, just like a sentinel event review.
If the health service does not intend to notify SCV of an event but you feel this should occur, we encourage you to escalate your concerns through the health service’s internal consumer liaison office. For all options to voice your concerns, please see 'Voicing your concerns about patient care' section below.
What does SCV do once a health service reviews a sentinel event?
In addition to health service reviews, SCV has partnerships with several independent bodies across Victoria that review patient deaths, including:
- Victorian Audit of Surgical Mortality (VASM)
- Victorian Perioperative Consultative Council (VPCC)
- Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM)
- Coroners Court of Victoria (CCoV)
Sometimes the findings from sentinel event reviews are provided to these agencies so that lessons learnt are shared across the health sector to help improve Victoria’s overall healthcare quality and safety.
The information SCV receives from sentinel event reviews is also used internally to drive improvement. You can read more about the program in the Sentinel event annual report.
What should I do if I’m not happy with the outcome of a review?
In the first instance, please contact the health service and raise your questions or concerns directly with them. If you’re not satisfied with the health service response, you can also reach out to the Health Complaints Commissioner (HCC). See below for more information about the HCC.
Voicing your concerns about patient care
Contact the health service
Victorian health services are expected to have a staff member available to patients, their family, carers or friends if they’re concerned about aspects of care in hospital. You can find the contact details for the consumer liaison on the health service website, or you can contact the health service by phone and ask for their consumer liaison office contact details.
If you want help making a complaint to a health service, please contact the SCV Consumer Feedback Team via firstname.lastname@example.org or 1300 543 916.
Contact the Health Complaints Commissioner
If you’ve raised your concerns with the health service directly, but you’re not satisfied with the response, you may wish to contact the HCC.
The HCC is an independent organisation in Victoria that works to find solutions for complaints about healthcare, and the way organisations manage patients’ health information.
The Health Complaints Commissioner can be contacted on 1300 582 113, or you can lodge an online complaint.
Open disclosure process and framework
The Australian Commission on Safety and Quality in Health Care (ACSQHC) defines open disclosure as the ‘open discussion of adverse events that result in harm to a patient while receiving healthcare, with the patient, their family and carers'.
The elements of open disclosure are:
- an apology or expression of regret, which should include the words ‘I am sorry’ or ‘we are sorry’
- a factual explanation of what happened
- an opportunity for the patient, their family and carers to relate their experience
- a discussion of the potential consequences of the adverse event
- an explanation of the steps being taken to manage the adverse event and prevent a recurrence.
Visit our duty of candour page to read more.