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1. Form a review team

Avoiding delays in your review will help you identify and act on areas that can be improved.

Find an external expert to help

Health services should have at least one independent member on their serious and sentinel event review panels.

Find an external expert through PEER.

Include a consumer representative 

A consumer representative will help you understand the patient perspective and highlight areas for improvement.

How to involve a consumer in a review.

Involve patients and families

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

Openly communicate with patients and their families/carers.

2. Conduct the review

Keep performance issues separate

Adverse patient safety event reviews should not be used to manage the performance of staff.

Manage review records and documents

All documents created during the adverse patient safety event review should be carefully distributed and securely stored.

Read our tips.

3. Develop, implement and monitor recommendations

Develop recommendations to eliminate, control or accept causal/contributory factors.

Make sure you follow up on whether they are implemented and track their impact on patient safety.

Reviewing events when patient deterioration was missed

Listen to this interview with Alfred Health's Rural Urgent Care Nursing Capability Development Program, where SCV's Joanne Miller talks about critical factors in missed patient deterioration.


Get in touch

Sentinel event program
Safer Care Victoria
1300 543 916

Page last updated: 04 May 2021

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