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This report provides the Victorian community and the health sector with information on the most serious adverse events reported in Victorian public and private hospitals, and ambulance services.

Sentinel events are the most serious adverse events that result in a patient dying or being seriously harmed.

Safer Care Victoria publishes this information every year to help Victorians understand what sentinel events have occurred, what has been learned and how we have improved as a result.

This report includes an overview of the sentinel events notified, recommendations for improvement arising from root cause analysis reviews and case studies from Victorian health services.

Page last updated: 11 Jan 2019

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