Health services must notify the most serious cases of patient harm and death that have resulted from adverse patient safety events, and make sure they are properly reviewed. We also follow up with health services to see if they have acted to help prevent further harm.
What do you have to report?
Adverse patient safety events that result in serious harm, or death of a patient while in the care of a health service. Serious harm is considered to have occurred when, as a result of the incident, the patient has:
- required life-saving surgical or medical intervention
- received a shortened life expectancy
- experienced permanent or long-term physical harm, or permanent or long-term loss of function.
Update: Healthcare Acquired COVID-19 Sentinel Events
Safer Care Victoria recommends that COVID-19 acquired within a healthcare setting, that results in serious harm or death of a patient, should be reported under Category 11, Sub-category 9 – Healthcare Associated Infection.
Safer Care has developed a Rapid adverse event review tool – COVID-19 related deaths occurring in health services that can be used by health services to review these events.
If a health service identifies a cluster of events (more than one), it is recommended they contact the Sentinel Events Program to discuss the notification.
Who needs to report?
All public and private health services, and all services under their governance structures. Examples of health services include:
- Ambulance Victoria
- bush nursing centres
- first aid services
- Forensicare (Thomas Embling Hospital)
- non emergency patient transport
- public sector residential aged care facilities
- hospital in the home services
- private day surgery facilities.
Unsure if you need to report?
Or contact our patient safety review team.
Notify us of a sentinel event
Follow our steps to notify and review a sentinel event, and implement your recommendations.
If the adverse event doesn't classify as a sentinel event, we recommend you still undertake a review. Read our guidance on how to do this.
Why reporting sentinel events is important
Listen to this interview with Alfred Health's Rural Urgent Care Nursing Capability Development Program, where SCV's Joanne Miller talks about the importance of reporting and learning from sentinel events.
What do we do with this information?
Every sentinel event is an opportunity to learn and get better – not just at an individual health service, but across the healthcare system.
We share those lessons through the Sentinel events annual report.
Page last updated: 25 Jul 2022