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Posted on 25 Jan 2021
Incident response/review

Maternity care, in-hospital falls and medication errors were the most commonly reported serious events that harmed patients in 2019/20, the latest Victorian sentinel events report shows.

While most healthcare in Victoria leads to good outcomes, there are times when things go wrong, and patients are harmed as a result. These events – referred to as sentinel events – are reported to Safer Care Victoria in order to share any lessons and improvements and to help prevent similar events.

Download the report

The latest report shows that between July 2019 and June 2020:

  • reporting increased – the number of sentinel events reported grew by 54 per cent to 186. We believe these improvements demonstrate a growing culture of transparency and increasing willingness to learn from patient harm. 
  • review teams are stronger – 51 per cent of review teams had a consumer representative and 85 per cent an external expert
  • improvement is happening as a result – through hospital reviews, 600 root causes were identified and 890 recommendations developed.

This report is an alert and a guide for health services and clinicians, highlighting the underlying systems issues that contribute to adverse patient safety events which are rarely isolated to one health service.

To maximise learning, the report includes in-depth information on three frequently reported issues:

  • maternity and newborn (19% of notified incidents) – 51 per cent of these were directly or indirectly related to the labour period
  • patient falls (13% of notified incidents) – Use of documentation and assessment tools were identified in 64% of root causes that contributing to falls 
  • medication safety (11% of notified incidents) – 50 per cent of medication safety incidents were classified und ‘heparin and other anticoagulants’.

Page last updated: 22 Sep 2021