Clinical risk management

Notifying & reporting sentinel events

Who should report?

All health services and agencies that identify an incident that reflects a national sentinel event definition are required to report the incident to the Sentinel event program.

Transition to VHIMS reporting

Over time the Victorian health incident management system (VHIMS) will replace the paper-based initial notification. The Department of Health will inform participating organisations when notification through VHIMS is the sole method of Sentinel event notification. In the interim, health services and agencies should continue reporting using the steps outlined below.

Step 1: Notification to the Department of Health

The Department of Health must be notified within 3 working days by emailing a completed Sentinel event reporting form to sentinel.events@health.vic.gov.au.

Sentinel event reporting form 2011-2012

On receipt of initial notification, the department will provide the health service with a Sentinel event reference number to be indicated on the root cause analysis (RCA) summary report.

Step 2: Commencement of the RCA

A RCA should be conducted for each sentinel event reported to the Department of Health:

• The RCA processes should commence as soon as practical after an incident.
• A RCA team should be convened as soon as practical after an incident occurs.

This step may commence at the same time as preparing the notification to the department. For more information about conducting a RCA.

Step 3: Documenting and submitting a RCA report

A de-identified RCA summary report is to be provided to the Department of Health within 60 days of notification to sentinel.events@health.vic.gov.au.

The RCA findings should be documented on the RCA summary report which includes a Risk Reduction Action Plan (RRAP).

Root Cause Analysis (RCA) Report 2011-2012 (v0.02) form

Step 4: Review and feedback on submitted RCAs

The Clinical Incident Review Panel (CIRP) reviews and provides expert commentary on submitted reports and recommendations. When appropriate, summaries may be sent to any of the relevant Consultative Councils (VCCAMM or VSCC) to review and provide comment on sentinel events within their area of expertise.

The Department of Health provides effective feedback to individual health services based on these deliberations.