Key messages

  • Sentinel events are a subset of adverse events that result in death or serious harm to a patient. 
  • All sentinel events are to be reported to Safer Care Victoria. 
  • A report must be submitted to Safer Care Victoria within three days of a sentinel event occurring. 
  • A root cause analysis must be conducted for each sentinel event reported to Safer Care Victoria.

Sentinel events are infrequent events that occur in health services as a result of systems and process deficiencies.

Sentinel event definitions

The first eight categories listed below are nationally defined sentinel event categories. Category 9, “Other catastrophic:  Incident severity rating one (ISR1)” is a Victorian defined category.

  1. Procedures involving the wrong patient or body part resulting in death or major permanent loss of function
  2. Suicide in an inpatient unit
  3. Retained instruments or other material after surgery requiring re-operation or further surgical procedure
  4. Intravascular gas embolism resulting in death or neurological damage
  5. Haemolytic blood transfusion reaction resulting from ABO incompatibility
  6. Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs
  7. Maternal death associated with pregnancy, birth or the puerperium
  8. Infant discharged to the wrong family
  9. Other catastrophic: Incident severity rating one (ISR1)

Episodes of suicide that are reportable under the Mental Health Act 2014 should also be reported to the Chief Psychiatrist.

Information regarding e-learning programs and Root Cause Analysis (RCA) training is available at RCA training dates

Reporting sentinel events

Please report any sentinel events to Safer Care Victoria.

Step 1: Notify SCV

Complete a sentinel event notification form

Email to sentinel events within three working days of the event occurring. 

We will provide you with a reference number to use for all correspondence relating to the event. We will also give you a date to submit your root causes analysis (RCA) report by. This will be 30 working days (six weeks) from the date of notification.

Step 2: Commence RCA

A RCA should be conducted for each sentinel event you report. 

We recommend that you convene a RCA team and start the RCA process as soon as possible after an incident occurs.

For more information, read our guide on how to form a RCA team and submit a RCA report within 30 working days.

Step 3: Submit a RCA report

Complete the RCA report template.

Email your deidentified report to sentinel events by the date we gave you at time of notification.

If you cannot meet the submission date, you may request an extension. 

Submit the extension request form at least seven days prior to the submission date. We will review your request and let you know if the extension is granted. 

Step 4: RCA review

SCV’s Incident Response Team will review your RCA report and provide you with any immediate feedback.  

We will then forward the final RCA report to the relevant experts in SCV or DHHS to provide feedback on the recommendations and the plan for shared learning. 

We will compile and provide you with final feedback. 

This review process is expected to take three weeks.

Step 5: Submit your RRAP

You should submit a risk reduction action plan (RRAP) feedback report three months after your RCA report was submitted. This details your progress in implementing the recommendations formed from the sentinel event review process. 

Complete the risk reduction action plan (RRAP) feedback report template

Email your RRAP feedback report to sentinel events

For Support with the sentinel event process please contact the Incident Response Team, Safer Care Victoria.

Sentinel event and RCA summary report

  • Sentinel events, Incident Response Team, Safer Care Victoria

    To notify a sentinel event and submit a root cause analysis (RCA) summary report

RCA training dates and venues

  • Sentinel events, Incident Response Team, Safer Care Victoria

    To find RCA training dates and venues, or to register for virtual refresher meetings