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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 hospitals must report sentinel events to Safer Care Victoria. We strongly encourage private hospitals to do the same.

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

Using our RCA risk reduction plan 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?

  1. Procedures involving the wrong patient or body part resulting in death or major permanent loss of function
  2. Suicide in an inpatient unit
  3. Retained instruments or other material after surgery requiring re-operation or further surgical procedure
  4. Intravascular gas embolism resulting in death or neurological damage
  5. Haemolytic blood transfusion reaction resulting from ABO blood group incompatibility
  6. Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs
  7. Maternal death associated with pregnancy, birth and the puerperium
  8. Infant discharged to the wrong family
  9. Other catastrophic: incident severity rating 1 (ISR 1)

Unsure if you need to report?

Please contact us if you are unsure if you need to report, or which category it fits under.

Get in touch

Incident Response Team
Safer Care Victoria
+61 3 9096 5445

Page last updated: 18 May 2018

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