Eliminating sentinel events

By Michelle McDade - November 28, 2017

Patients and consumer groups rightly expect the healthcare sector to continue to focus on improving patient safety and quality.

Renowned international leader in this field, Dr Raj Behal visited Pitcher Partners Melbourne recently to share his insights and ideas with some of our colleagues and clients.

Having worked within the healthcare sector for more than 20 years, Dr Behal says the resounding issue in value-based care is achieving the best patient-desired outcomes, at the lowest feasible cost of care.

Dr Behal believes most of the problems leading to less-than-optimal patient safety are due to two main issues: 

  1. the way systems are set up,
  2. and how we approach improvement.

I have been working with Dr Behal over a number of years to develop and introduce these concepts to hospitals in Australia and overseas.

Increasingly, hospitals in Australia are adopting Dr Behal’s SafetySteps framework, designed to reduce harm by focusing on human factors and systems design. SafetySteps applies a ‘100 point plan’ approach to the recommendations from clinical incident reviews. For each recommendation, points are awarded.  This 100 point system involves:

The closer the score to 100 points is, the more effective the reduction of clinical incidents will be. Hospitals with SafetySteps in place have built this framework into their clinical incident review process. One USA based hospital with SafetySteps in place has reported zero never events[1] (similar to sentinel events) for a year, and no perioperative mishaps for over 800 days.

Pitcher Partners will continue to work with Dr Behal to share the beneficial impact of SafetySteps across the Australian healthcare sector. If you would like to know more about the potential of SafetySteps, please contact Michelle McDade or your Pitcher Partners expert.

Michelle McDade is a Client Director in Pitcher Partners Consulting (PPC) Melbourne, and a Lead in PPC healthcare sector practice.

Contact our experts

Other articles


Top of Page


Rob Southwell

Rob Southwell's picture


Managing Partner and Partner – Private Business and Family Advisory

> View profile

Leon Mok

Leon Mok's picture


Managing Director

> View profile

Brendan Britten

Brendan Britten's picture


Managing Partner and Executive Director/Partner- Business Advisory and Assurance

> View profile

Nigel Fischer

Nigel Fischer's picture


Managing Partner - Private Business and Family Advisory

> View profile

Michael Minter

Michael Minter's picture


Managing Partner

> View profile

Tom Verco

Tom Verco's picture


Managing Principal - Private Business and Family Advisory

> View profile

Partnership fraud


Paperwork and independent advice saves partnerships from fraud

Discover more

Kia Ora Horse Stud


Pitcher Partners fills a Financial Manager gap to keep the business on track

Discover more

Fuel Injection Company Administration


A fuel injection company began life as an Australian public company before being acquired by a UK publicly listed company while in the research and development stage of a “green...

Discover more

@PitcherPartner Good luck to Andrew Beitz, Principal of our Adelaide firm, who is competing in the 2018 Lifesaving World Championsh… https://t.co/9vucR2xzj2