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Sentinel events are the most serious adverse patient safety events in our healthcare system. And it’s important that we all learn from them.

That’s why we release this report every year – to share what we have learnt and to help health services prevent similar events.

Between July 2021 and June 2022:

  • 240 sentinel events were reported to us
  • 88 per cent of review panels included consumer representation
  • 1149 recommendations for improvement were developed from the review of sentinel events.

Read our report for more insights, recommendations and examples of health services leading the way in preventing patient harm.

What’s new?

This year, we focused on four sentinel event themes:

  • increased notification of sentinel events
  • engagement with patients, families and carers
  • delays in recognising or responding to deteriorating patients
  • monitoring of recommendations


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