sentinel events were reported to Safer Care Victoria
Download the report
About the report
Sentinel events are the most serious adverse patient safety events in our healthcare system and it’s important that we all learn from them.
"Every sentinel event represents a person, a family and a healthcare team whose lives have been profoundly affected. While we cannot change what has happened, we can honour those experiences by learning from them.
At Safer Care Victoria, we partner with consumers, families, carers, clinicians and health services to better understand the factors that contribute to these events and to translate those insights into meaningful improvements across the health system. Every lesson learned is an opportunity to strengthen patient safety, prevent future harm and help ensure safer care for all Victorians."-Louise McKinlay, CEO, Safer Care Victoria.
The report shows that between 2024-25 financial year:
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217
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682
findings were identified
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463
lessons learnt
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99%
of review panels included consumer representation
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99%
of review panels included an external expert
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915
recommendations were made
What’s new?
This year's focuses on the following four key themes:
Perioperative (surgery related)
Reviewing events to strengthen responses to patient deterioration, adherence to protocols and policies and improve communication within post-surgery care teams.
Maternity and paediatrics
Analysing events to identify ways to improve outcomes for mothers, babies and children through enhanced systems and improved partnerships with families and carers to better recognise deterioration and escalation of care.
Mental health
Enhancing support and interventions post discharge to decrease the risk of self-harm through adopting the Zero Suicide Framework Initiative.
Medication errors
Identifying system issues to promote safer medication management, particularly for anticoagulants, which continue to be the leading cause of medication-related sentinel events.
Learning from sentinel event reviews and data is key to continuous improvement in health services, including improving quality and safety outcomes for consumers, families and carers. Read our report for more insights, recommendations and examples of health services leading the way in preventing patient harm.