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Posted on 29 Jan 2020
Incident response/review

By Prof Euan Wallace AM, CEO Safer Care Victoria

The author and blogger Frank Sonnenberg penned “Smart people do stupid things. Stupid people don’t learn from them.” He could have been commenting on sentinel events and lessons learnt from them. He wasn’t, but he could have. Had he been, this year’s sentinel event report suggests that we are getting smarter. How so? Because, released today, the 2018-19 sentinel events annual report shows that Victorian health services found more than 600 ways to learn from error and improve the quality and safety of the care we provide.

Download the report

Sentinel events are the most serious adverse events in our healthcare system. Most, but not all, sentinel events are avoidable. This is the reason that an in-depth review – a root cause analysis (RCA) – of each sentinel event is required. The intent is to understand how the event happened and to learn from it with the intent of preventing a similar event in the future. The learning requires three things.

First, that all sentinel events are recognised and reported. While the number of sentinel events reported this year has remained steady, for the first time this includes private hospitals. I suspect that we are still not reporting all sentinel events. There are many reasons for that. At Safer Care Victoria we are looking at ways of presenting event rates across health services as a means of supporting reporting. 

Second, the review (RCA), needs to be of high quality. There is clear evidence in this year’s report that RCA quality is improving greatly. Health services are to be congratulated on this. More external experts, more consumer involvement, better timeliness. While process rather than outcome  measures of quality these are, nonetheless, measures of improvement. Well done to those involved.

Third, meaningful and deliverable improvements (recommendations) that are implemented are the end game of the entire process. Not to mix too many metaphors, there is light at the end of that tunnel too. This year’s report shows more and stronger recommendations than ever. The new action plans and “closing the loop” reporting also looks promising and useful. Perhaps more on that next year.

So, does the sentinel event program improve care and save lives? That’s its principal purpose after all. To be fair, it’s too early to tell at a system level. Anecdotally, at an individual health service level, then resoundingly yes. But that’s wholly dependent on a curious and psychologically safe workforce. That’s the piece that can’t be processed. That’s where local leadership rules.

Page last updated: 31 Jan 2020