Australian Sentinel Events

Australian Sentinel Events or National Sentinel Events (commonly abbreviated as SEs). Is an Australian national medical error or incident reporting system. It includes a set of preventable adverse events that result in serious harm or death to a patient. These events are clearly defined and recognized as being preventable if the proper safeguards are in place.

The report of SEs is mandatory for all public hospitals and all private licensed health care facilities across Australia.

The SEs include 10 categories, however each states and territories may have additional categories on the Sentinel Events.

History

In 2002, Australian States and Territories agreed to contribute to a set of eight core National Sentinel Events (NSEs). A revised Australian Sentinel Events (ASE) list was endorsed by Australian Health Ministers in December 2018. ASE includes 10 categories.

All Australian Jurisdictions

The table below is the total of the 10 categories of Sentinel Events (SEs) across all states and territories in Australia.

The table does not include additional categories of SEs and Other SAC1 Clinical Incidents or other Harm Score 1 incidents.

Selected sentinel event	2019-2020	2020-2021	2021-2022
Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death	2	5	1
Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death	1	0	0
Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death	0	1	2
Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death	7	6	5
Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death	0	0	1
Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward	15	18	16
Medication error resulting in serious harm or death	25	49	35
Use of physical or mechanical restraint resulting in serious harm or death	3	0	1
Discharge of an infant or child to an unauthorised person	0	0	0
Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death	4	3	3
Total Events	57	82	64

New South Wales

The table below is the 10 categories of sentinel events in NSW. The table does not include other Harm Score 1 incidents.

Selected sentinel event	2019-2020	2020-2021	2021-2022
Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death	0	2	0
Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death	0	0	0
Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death	0	0	0
Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death	1	2	1
Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death	0	0	0
Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward	2	4	7
Medication error resulting in serious harm or death	3	11	1
Use of physical or mechanical restraint resulting in serious harm or death	0	0	0
Discharge of an infant or child to an unauthorised person	0	0	0
Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death	3	0	3
Total Events	9	19	12

Victoria

The table below is the 10 categories of sentinel events in Victoria. The state of Victoria has an additional category for the event which is “All other adverse patient safety events resulting in serious harm or death”.

Selected sentinel event	2019-2020
Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death	0
Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death	2
Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death	0
Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death	0
Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death	0
Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward	8
Medication error resulting in serious harm or death	12
Use of physical or mechanical restraint resulting in serious harm or death	1
Discharge or release of an infant or child to an unauthorised person	0
Use of an incorrectly positioned or- or naso- gastric tube resulting in serious harm or death	0
All other adverse patient safety events resulting in serious harm or death	163
Total	186

Queensland

The table below is the sentinel events in Queensland.

sentinel event	Incidents
2015/16	15
2016/17	2

Western Australia

In Western Australia, the sentinel events will be reported as SAC1 which includes the 10 categories of National Sentinel Events and Other SAC1 clinical incidents.

SAC1	2019-2020	2021-2022
Sentinel Events	12	26
Other SCA1 clinical incidents	519	574

Southern Australia

The table below is the 10 categories of the sentinel events in South Australia.

There are total of 5 sentinel event in 2021-2022 which is the same as 2022-2023.

Selected sentinel event	2022-2023
Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death	0
Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death	0
Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death	1
Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death	0
Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death	0
Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward	0
Medication error resulting in serious harm or death	4
Use of physical or mechanical restraint resulting in serious harm or death	0
Discharge or release of an infant or child to an unauthorised person	0
Use of an incorrectly positioned or- or naso- gastric tube resulting in serious harm or death	0
Total	5

Northern Territory

The table below is the incidents number of sentinel events which also include the 10 categories since 2019 and 8 core categories before 2019.

sentinel event	Incidents
2011/12	0
2012/13	1
2013/14	2
2014/15	2
2015/16	0
2016/17	1
2017/18	2
2018/19	0
2019/20	0
2020/21	2