Sentinel events
Health services must report the most serious cases of patient harm and death caused by adverse patient safety events, and make sure they’re properly reviewed. SCV also follows up with health services to check they’ve acted to help prevent further harm.
Shared decision making community of practice
Are you interested in shared decision making in healthcare?
Has your health service identified the shared decision making domain from the Partnering in healthcare framework as a priority?
Involve consumers in incident reviews
Involving consumer representatives when reviewing adverse events can challenge assumptions and highlight areas for improvement.
Consumer representatives are not directly affected by the event being reviewed, but they can help to provide the perspective of the patient, their family, or carer.
Our guides helps you:
- select and appoint a consumer representative
- clarify their role and remuneration
- support them through the process.
Frailty recognition and response in the community
COMPLETE
Summary
It is estimated that more than a quarter of older adults are frail, making them more likely to have poor health outcomes. With an ageing population, itimely recognition of frailty followed by an evidence-based intervention can improve health outcomes.
We partnered with five health services to introduce an approach to frailty screening and management - recognising and providing timely intervention to patients presenting with frailty and pre-frailty.
Notify and review a sentinel event
There are mandatory timelines around sentinel events reporting, reviews and recommendations.

What to report
In Victoria, sentinel events fall under 11 categories – 10 of which are standard across the country.
Establishing the Victorian ECMO service
Complete
Summary
Extracorporeal membrane oxygenation (ECMO) gives temporary life-support for critically ill patients with reversible acute respiratory and cardiac failure, and patients requiring a ‘bridge’ to transplantation.
It is a high-risk procedure that requires highly skilled and experienced clinicians. It is not a common procedure but can be lifesaving.
This project:
Better Births for Women Collaborative
complete
Summary
Women having their first birth vaginally in Victoria are four times more likely to experience a severe perineal laceration (third- or fourth-degree tear) compared to those having a subsequent birth vaginally (Victorian perinatal services performance indicators 2018–19 report).
This can have devastating long-term or lifelong impacts on physical and psychological wellbeing. Many of these tears are avoidable.
Safer baby
complete
Summary
Research suggests that many stillbirths may be avoidable. We also know there is low awareness of the risk factors for stillbirth.
We teamed up with the Institute for Healthcare Improvement (IHI) and the Stillbirth Centre for Research Excellence (CRE) to improve outcomes for mothers and their babies, using the IHI’s proven Model for improvement.