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Sentinel events are unexpected events that result in death or serious harm to a patient while in the care of a health service.

In Victoria, public and private hospitals must report sentinel events to Safer Care Victoria. 

Services required to report sentinel events include:

  • Public and private health services and all services under their governance structure
  • Ambulance Victoria
  • Bush nursing centres (publicly funded)
  • Forensicare (Thomas Embling Hospital).

Involved in an incident review?

Make sure you keep the right documents during and after an incident review. Read more

How to report a sentinel event

Step one - notify SCV

Email your completed Sentinel event notification form within three days of the event occurring.

Step two - root cause analysis

  1. Commence a root cause analysis as soon as possible after the event.
  2. Using our Root cause analysis form (below), email your RCA report to us within 30 working days (six weeks).
  3. Our Incident Response Team will review your report and provide feedback within three weeks.

Step three - risk reduction plan feedback report

Using our RCA risk reduction action plan feedback report template (below), email your Risk reduction plan to us within three months of your RCA report.

This extra step helps you track progress in implementing the recommendations from a sentinel event.

What must you report to us?

National and state sentinel event categories will change on 1 July 2019.

View the 10 national categories

Download our guide on the Victorian-only category 11

Download our poster to display in your health service

NEW category

Previous category

What does this mean?

1. Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death.

1. Procedures involving the wrong patient or body part resulting in death or major permanent loss of function

This does not add any notification requirements, it splits the existing category into three.

2. Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death

3. Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death

4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death

3. Retained instruments or other material after surgery requiring re-operation or further surgical procedure

Only notify under this revised category if an unretrieved objects has caused harm or death.

5. Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death

5. Haemolytic blood transfusion reaction resulting from ABO incompatibility

No change in notification.

6. Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward

2. Suicide of a patient in an inpatient unit

The new category is just for acute psychiatric services.

For suspected suicides in areas outside of acute psychiatric units please notify under the new Category 11.

7. Medication error resulting in serious harm or death

6. Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs

No change in notification.

8. Use of physical or mechanical restraint resulting in serious harm or death

 

NEW Please notify if serious patient harm or death has occurred while being held down by staff/security, or with the use of soft restraints to a chair or bed.

9. Discharge or release of an infant or child to an unauthorised person

8. Infant discharged to the wrong family

No change in notification.

10. Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death

 

NEW Please notify serious harm cause by events such as Incorrect placement and use of a feeding tube.

11. All other adverse patient safety events resulting in serious harm or death

9. Other catastrophic: incident severity rating 1 (ISR 1)

Guidance to come.

 

7. Maternal death associated with pregnancy, birth and the puerperium

REMOVED However, please notify maternal deaths under the new Category 11.

 

4. Intravascular gas embolism resulting in death or neurological damage

 

Will there be changes to the Victorian category?

Yes, we have updated the Category 11 (formerly Category 9) to align with the national changes.

Category 11 includes adverse patient safety events that do not fit into any of the 10 national categories but have resulted in serious harm or death.

We will release new forms closer to 1 July.

Unsure if you need to report?

Contact our incident response team on (03) 9096 1546 or email sentinel.events@safercare.vic.gov.au

Guide and poster

Get in touch

Incident Response Team
Safer Care Victoria
+61 3 9096 1546

Page last updated: 18 Jun 2019

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