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Under Victoria’s sentinel events program, health services are required to:

  1. notify SCV within three business days of becoming aware of the event
  2. review and analyse the sentinel event using root cause analysis (RCA) methodology
  3. submit an RCA report (parts A and B) within 30 business days (six weeks) of the notification
  4. submit recommendations from the RCA
    (part C) within 50 business days (10 weeks) of the notification
  5. submit a recommendation monitoring report within 120 business days of the notification.

Graphic showing the timeline for reporting a sentinel event

Step one - notify SCV

Email your completed Sentinel event notification form (below) within three business days of becoming aware of the sentinel event.

Step two - root cause analysis (RCA)

  1. Form a review team that includes
  • a member who is external to the health service 
  • a consumer representative
  1. Commence a review of the sentinel event using the RCA method.
  2. Email the Root cause analysis part A and B report template (below) to us within 30 business days (six weeks) of the notification date.
  3. Email the Root cause analysis part C report template (below) to us within 50 business days (ten weeks) of the notification date.

Step three - feedback on sentinel event RCA report

Our Incident Response Team will review your reports and provide feedback within three weeks.

If you require an extension for the report submission, please submit this form to SCV at least five business days before part A and B of the report are due. The extension will apply to the whole report. A maximum extension of four (4) weeks is available.

When reviewing a sentinel event…

Include external members and consumer representatives

All teams reviewing sentinel events should include an external member and a consumer representative. Visit our PEER platform to find an external team member. For support on having consumer representatives on reviews check out our information for health services and consumer representatives.

Include all services involved

When a sentinel event occurs across multiple health services, all services involved in the care of the patient should participate in a multi-agency review of the event.

The health service that provided the final care are responsible for notifying the event, initiating the RCA review and engaging the other services.

Involve patients and families

Please consider the patients, their families, carers or friends during the review process. Families can provide crucial and insightful information during the review of a serious adverse event.

Keep performance issues separate

The RCA methodology should not be used for performance-management issues. These issues should be handled by the relevant personnel in a performance-management context.

Page last updated: 04 Jul 2019

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