Sentinel events are the most serious adverse patient safety events in our healthcare system and it’s important that we all learn from them.
While most healthcare in Victoria leads to good outcomes, there are times when things go wrong, and patients are harmed as a result. “Patient harm in healthcare is never acceptable – we must learn from every sentinel event to ensure whatever led to an adverse event is not repeated. Reporting sentinel events is what makes our system stronger”. says Louise McKinlay, CEO Safer Care Victoria.
Between 1 July 2023 and 30 June 2024:
- 193 sentinel events were reported to us
- 95 per cent of sentinel event reports included a consumer representative
- 758 recommendations for improvement were developed from the review of sentinel events.
What’s new?
This year, we focused on three sentinel event themes:
- a review of sentinel events involving patients from diverse backgrounds, with a focus on patients with First Nations heritage highlighting the importance of cultural safety
- events related to clinical process and procedure, with a focus on colonoscopy care
- events related to mental health care.
Learning from sentinel event reviews is key to continuous improvement and achieving the aim of harm reduction and improving patient safety. Read our report for more insights, recommendations and examples of health services leading the way in preventing patient harm.