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Posted on 22 Mar 2022
Incident response/review

Going beyond blaming human error, health services are encouraged to dive deep into the contributing factors behind the most serious cases of patient harm in Victoria.

That is the strong message out of the 2020-21 Sentinel events annual report, which details adverse patient safety events reported to us, the findings from health service reviews, and recommendations.

While most healthcare in Victoria leads to good outcomes, there are times when things go wrong, and patients are harmed as a result. And it’s important that we learn from them and find ways to improve.

While health service reviews continue to get stronger every year, with growing involvement of external experts and more input from the affected patient or their family, there is room for improvement.

  • Take a deeper look into contributing factors that led to the sentinel event. Around 10 per cent of the total findings and lessons learned referred to human error. While this is an improvement from 18 per cent in 2019–20, many reviews could have looked further into the working conditions and environment that contributed to the human error.
  • Develop recommendations to focus on systems issues rather than human error or patient factors. Some strong examples focused on standardisation, architectural changes, forcing functions and tangible involvement by leadership.
  • Involve a consumer representative on your review team. More than half of the review panels did not include the important patient voice and perspective.
  • Keep reporting sentinel events. 168 sentinel events were reported to us, which is down from last year. 

To maximise learning and improvement opportunities, the year’s report focuses on three main themes: mental health, residential aged care and COVID-19.

This report is a great resource for all health services – there is a lot you can learn from our in-depth analysis of common themes and examples of service level changes that made a difference. The underlying systems issues that contribute to adverse patient safety events are rarely isolated to one health service.

Page last updated: 24 Mar 2022