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Posted on 28 May 2019
Incident response/review
Quality/safety improvement
Safety cultures

From 1 July 2019, hospitals will notify the most serious adverse events under 11 updated sentinel event categories.

The Australian Commission on Safety and Quality in Health Care increased national sentinel event categories from eight to 10. Following suit, Safer Care Victoria has updated the Victorian-only category 11.

What’s changing?

Hospitals will now have to notify serious harm or death caused by:

  • use of physical or mechanical restraints
  • incorrectly positioned oro- or naso- gastric tubes (e.g. feeding tube).

Hospitals will still have to notify the following events, just under slightly different categories:

  • surgical procedures involving the wrong patient or body part – the previous category has been split into three
  • suspected suicides outside of acute psychiatric services – notify under Category 11
  • maternal death associated with pregnancy, birth and the puerperium – notify under Category 11.

View our summary of changes for each category

We will provide more guidance and notification forms closer to 1 July.

Review timelines are now longer

From 1 July, hospitals will also be given more time to review a sentinel event to form strong and impactful recommendations.

You are still required to notify us of a sentinel event within three days.

On top of the 30 business days you have to undertake a root cause analysis review, you will now have another 20 business days to form recommendations.

Use this extra time to consult with clinicians and other key stakeholders on how to resolve the problems you have identified through you review.

Safer Care Victoria oversees these reports to make sure Victorian hospitals learn and improve every time a patient is harmed.

Read more about the sentinel events program

Page last updated: 20 Aug 2019