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Posted on 28 Jan 2020
Incident response/review

Victorian health services found more than 600 ways to improve the quality and safety of their care, following the review of the most serious cases of patient harm and death.

Released today, the 2018–19 sentinel events annual report summarises the number and type of serious adverse events that have affected people’s lives, as well as the work undertaken to make healthcare safer.

The 2018–19 report shows:

  • after significant increases over the past few years, the number of sentinel events reported remained steady at 121 notifications
  • the review of these events is more robust, with 85 per cent involving an external, independent member, and a third involving a consumer representative
  • reviews are more timely, with 35 per cent of review reports submitted within 30 working days (up from 18 per cent last year)
  • more services are formally following up on their recommendations.

Download the report

“Every serious adverse event is an opportunity to learn and get safer,” SCV CEO Prof Euan Wallace AM said.

“Great improvements have been made over the past year in terms of reporting, response times, review strength and resulting improvements. But more work can be done – we would like to see all sentinel events notified to us so we can learn from each other to build safer, better healthcare.”

As the state’s lead agency for healthcare quality and safety, SCV assumed responsibility for the Victorian sentinel events program when it was established in January 2017.

SCV is now collecting more information around sentinel events than ever before to inform improvement work. It is currently working on guidance in response to sentinel event outcomes, including:

  • responding to patients who are clinically deteriorating
  • managing patients with delirium, which can cause in-hospital falls
  • managing patients with swallowing difficulties
  • responding to difficult behaviours.

For advice on sentinel event notification, review and improving systems of healthcare, please contact the incident response team at

Page last updated: 31 Jan 2020