Australian Sentinel Events
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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.[1][2]
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. [3]
History
[edit]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.[1]
All Australian Jurisdictions
[edit]The table below is the total of the 10 categories of Sentinel Events (SEs) across all states and territories in Australia. [1]
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
[edit]The table below is the 10 categories of sentinel events in NSW.[1] 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
[edit]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”.[3]
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
[edit]The table below is the sentinel events in Queensland.
sentinel event | Incidents |
---|---|
2015/16[4] | 15 |
2016/17[4] | 2 |
Western Australia
[edit]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.[5]
SAC1 | 2019-2020[6] | 2021-2022[6] |
---|---|---|
Sentinel Events | 12 | 26 |
Other SCA1 clinical incidents | 519 | 574 |
Southern Australia
[edit]The table below is the 10 categories of the sentinel events in South Australia.[7]
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 |
Tasmania
[edit]Northern Territory
[edit]The table below is the incidents number of sentinel events which also include the 10 categories since 2019 and 8 core categories before 2019. [8]
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 |
Australian Capital Territory
[edit]Other territories
[edit]Refernece
[edit]This article has not been added to any content categories. Please help out by adding categories to it so that it can be listed with similar articles. (August 2024) |
- ^ a b c d NSW Government (n.d.). "Sentinel events". Sentinel events reporting.
- ^ IHPA. "Pricing and funding for safety and quality: Sentinel events" (PDF).
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at position 44 (help) - ^ a b ""Supporting patient safety: learning from sentinel events" annual report 2019-20" (PDF).
- ^ a b Caldwell, Felicity (2018-01-30). "Sorry, wrong patient: Major Queensland hospital errors revealed". Brisbane Times. Retrieved 2024-08-31.
- ^ "WA Health System SAC" (PDF).
- ^ a b Hastie, Hamish (2023-03-23). "Missing WA hospital safety report shows jump in number of worst clinical mistakes". WAtoday. Retrieved 2024-08-31.
- ^ Government of South Australia. (2023). Patient Safety Report 2023.https://www.sahealth.sa.gov.au/wps/wcm/connect/1b029a77-8634-49a5-991d-f87612d583c6/Final Patient Safety Report 2023.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-1b029a77-8634-49a5-991d-f87612d583c6-oHu9fVm
- ^ "Royal Darwin Hospital patient died due to 'medication error', remote NT patient seriously harmed, data shows - ABC News". amp.abc.net.au. Retrieved 2024-08-31.