Safer Care Victoria has released our 2021-22 Sentinel Events Annual Report
The annual report shares information about the most serious adverse patient safety events in our healthcare system, known as sentinel events. The Sentinel Events Annual Report identifies important learnings that support health services to act to reduce the risk of similar events happening again and improve the safety of our healthcare system.
Every sentinel event is a tragedy that deeply impacts families and carers, and the hard-working clinicians who have dedicated their lives to helping people and providing high quality care.
We are committed to learning from every sentinel event, to honour those impacted, and to reduce the risk of it happening again.
What does the report show?
Across the 2021-22 reporting period, Victorian health services continued to demonstrate their commitment to improving the safety of our healthcare system by recognising and responding to adverse patient safety events.
Safer Care Victoria was notified of 240 sentinel events in 2021-22, resulting in 1,149 recommendations to drive improvements across our healthcare system. This represents a 43 per cent increase in sentinel events notified compared to the previous year and is a continuation of the year-on-year trend we’ve seen since Safer Care Victoria assumed responsibility of the sentinel event program in 2017.
While the factors underpinning these increases are complex, we believe this trend demonstrates a growing culture of transparency and an increasing willingness to act to reduce preventable patient harm.
In 2021-22 we also saw an increase in sentinel events related to patient deterioration, particularly in children and young people. This report details the work we are leading in response to this increase and outlines the actions we are taking in close partnership with health services, clinicians, patients, and families.
What is happening in response to these findings?
Safer Care Victoria proactively brought together more than 100 health care leaders, clinicians, patients, and families to consider how we might improve the safety and quality of care for children accessing emergency healthcare in Victoria.
This resulted in three key recommended actions:
• Deliver a state-wide patient escalation process, empowering patients and carers to voice unresolved concerns and receive timely responses from their health service.
• Implement a 24/7 system of virtual paediatric emergency consultation, with appropriate infrastructure, training and quality assurance and video links to clinicians with paediatric expertise and retrieval services.
• Mandate the use of Victorian Children’s Tool for Observation and Response (ViCTOR) wherever children and young people have vital signs recorded.
To progress this work Safer Care Victoria has launched Safer Care for Kids, a project that will co-design and implement all three recommendations in close partnership with affected families, the health sector, and the Department of Health.
What is Safer Care for Kids?
Safer Care for Kids will deliver all three recommendations to improve health outcomes for children needing emergency care. The project will be developed in partnership with families who have lived experience of sentinel events involving children and in close consultation with health services across Victoria.
Firstly, Safer Care for Kids will deliver a new family escalation system for Victoria. The escalation system will be available across the state and will give families an alternative pathway to raise concerns about their child’s deterioration.
A virtual paediatric consultation system will also be introduced, which will provide 24-hour access to specialist paediatric experts and services. This will be particularly beneficial to smaller regional health services when treating acutely unwell children.
The third change to be implemented will be to mandate the use of standardised and age-specific charts whenever a child’s vital signs are recorded. The standardised charts, known the Victorian Children’s Tool for Observation and Response (ViCTOR), are already used in many Victorian health services and assist in recognising and responding to clinical deterioration in children.
Safer Care Victoria has commenced engagement with families and health services, and we invite anyone interested in participating in the project to register their interest.
We expect the planning and consultation phase to take around 3-6 months followed by design and testing. While the implementation timelines will be determined through the planning process, we aim for Safer Care for Kids to go live in 2024.
If you are a patient, parent, carer or clinician who would like to be involved in the Safer Care for Kids project, please complete an expression of interest before 24 September 2023.
Frequently asked questions
Why were more sentinel events notified in 2021-22?
The increase in sentinel events notified to Safer Care Victoria in 2021-22 is consistent with the year-on-year trend we’ve seen since SCV assumed responsibility of the sentinel event program in 2017. While the factors underpinning these increases are complex, we believe this trend demonstrates a growing culture of transparency and an increasing willingness to act to reduce preventable patient harm.
We expect this number to continue to increase as we continue to drive awareness of the importance of reporting and learning from these events to prevent future harm.
Why are these events happening?
The causes of sentinel events are often complex and vary between cases. Sentinel event reviews focus on the system-level factors that contribute to patient harm. These can relate to gaps in communication or processes, capability or workforce issues, the physical environment and a range of other extenuating circumstances.
This report has identified patient deterioration as a significant factor behind the sentinel events reported in 2021-22. It has also identified a need to engage patients, families, and carers more closely and to ensure the follow-up of family concerns.
Why were there more sentinel events involving children in 2021-22?
The increase in notified paediatric sentinel events across this reporting period was from 12 per cent of the total number of sentinel events in 2020-21 to 16 per cent of the total in 2021-22, with deterioration reported as the most common risk factor. While the increase may be the result of greater transparency in reporting, which we have seen overall, whenever a child has experienced harm, it is important that we understand what went wrong to prevent it from happening again.
In response to the increase, Safer Care Victoria proactively engaged with health sector leaders, paediatric specialists, patients, and families, to gain a deeper understanding of the underlying issues and consider opportunities for improvement. This resulted in the series of recommendations that underpin Safer Care for Kids.
What is Safer Care for Kids?
Safer Care for Kids is a family-led project aimed at improving health outcomes for children in emergency care. It will be designed in close consultation with health services across the state to deliver on three key recommendations including a new family escalation system for Victoria, a 24/7 virtual paediatric consultation system, and mandate the use of standardised and age-specific charts (ViCTOR) whenever a child’s vital signs are recorded.
Safer Care for Kids will be developed in partnership with families who have lived experience of sentinel events involving children and in close consultation with health services across Victoria. The project was launched by the Minister for Health and will be implemented by Safer Care Victoria and the Department of Health. Over 100 clinicians, health sector leaders, patients and carers from across Victoria are behind the three key recommendations that underpin Safer Care for Kids. We invite anyone interested in contributing to the project to get involved by registering their interest.
How will the escalation process work?
Safer Care for Kids will be designed in close collaboration with families and health services. While the detail of how the escalation process will work will be determined through the planning phase of the project, in other jurisdictions it is centred around an external hotline. If families are concerned that their child is deteriorating and they are not being heard, they can call a hotline number, which is displayed on posters throughout the hospital, and speak to an external specialist. That specialist then formally escalates the families concerns to ensure they receive the care that they need.
Health Services across Victoria have existing escalation processes and the Safer Care for Kids escalation process will be designed in a way that complements these systems.
Do hospitals already have escalation processes?
Victorian health services have a range of existing escalation processes and we will work in close partnership with them to ensure that Safer Care for Kids integrates with and supports their wider systems. The launch of Safer Care for Kids follows the successful implementation of similar processes in other jurisdictions, most notably Ryan’s Rule in Queensland. The project is about providing patients and families with a consistent approach to escalation across the State.
Isn’t virtual care already available?
The Virtual Victorian Emergency Department already provides virtual care for adults and children outside hospital. The Paediatric Infant Perinatal Emergency Retrieval service provides a service primarily for children already in hospital. Safer Care for Kids will build on these existing services to ensure 24-hour access to specialist paediatric experts and services. This will be particularly beneficial to smaller regional health services when treating acutely unwell children.
What are ViCTOR charts?
ViCTOR - Victorian Children’s Tool for Observation and Response - is a set of standardised evidence-based tools to help health services develop more robust mechanisms to detect and respond to deterioration if children and young people in care. ViCTOR resources can be accessed via The Royal Children's Hospital Melbourne education hub and more information can be found on the Safer Care Victoria website.
Will Safer Care for Kids be rolled out across all health services?
The intention is for Safer Care for Kids is to be available across every health service, both public and private. We will work closely with health services and the Department of Health to implement this across the state.
When will this come into effect?
Safer Care Victoria has commenced engagement with families and health services, and we invite anyone interested in participating in the project to register their interest. We expect the planning and consultation phase to take around 3-6 months and followed by design and testing. While the implementation timelines will be determined through the planning process, we are aiming for Safer Care for Kids to go live in 2024.
What will Safer Care for Kids mean for health professionals and Emergency Departments?
Safer Care Victoria will consult closely with health services, specialists, patients, families and a wide range of stakeholders to ensure that these services support frontline health professionals, particularly those in emergency departments. We recognise their incredible work and commitment to providing Victorians with outstanding care. Many frontline health professionals have already consulted on the project and have been a driving force behind it.
Where can I get more information?
We will continue to provide updates as the Safer Care for Kids project progresses. If you would like to sign up to receive future communications about Safer Care for Kids, please register your interest in the project and select the option to join the Safer Care for Kids mailing list.
Last updated 06 Aug 2023