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Posted on 11 Jan 2019
Incident response/review
Safety cultures

The number of reported sentinel events are at their highest ever, showing greater transparency around the most serious adverse events in our public and private hospitals.

Released today, Safer Care Victoria’s sentinel events annual report for 2017–18 shows:

  • reported events increase by 69 per cent to 122, the highest since reporting began
  • timeliness of reporting has improved, with a quarter of the reports coming within three days
  • more review teams are involving external or consumer members – 80 per cent involved an external person, and 17 per cent involved a consumer
  • hospitals are making stronger recommendations out of a review – the number of reviews resulting in zero recommendations halved, and one third of reviews resulted in at least one strong recommendation
  • more hospitals are sharing their progress – 42 feedback reports were submitted, compared to three in 2016–17.

Download the report 

“For the third year in a row, we’ve seen an increase in the number of sentinel events notified. This is not a sign that our healthcare is any less safe. In fact, it shows our health services are effectively turning around a history of under-reporting,” CEO Professor Euan Wallace said.

“Great improvements have been made over the past year in terms of reporting, response times and resulting improvements. 

“In the next year, we want to see improvement in the reporting of hospital-acquired infections. In 2017–18 we had only one sentinel event notified, while the department had one hundred. I am sure a number of these would fit the criteria for sentinel event notification and are missed opportunities to learn.”

As the state’s lead agency for healthcare quality and safety, SCV assumed responsibility for the Victorian sentinel events program when it was established in January 2017.

For advice on sentinel event notification, review and improving systems of healthcare, please contact the incident response team at

Page last updated: 11 Jan 2019