Incident management and sentinel events

Incident management

An incident is an event or circumstance that resulted, or could have resulted, in unintended or unnecessary harm to a patient or consumer; or a complaint, loss or damage.

In Australia, hospital patient safety incidents are captured through local incident management systems. There are well established and effective process for data analysis and investigations. The Commission is currently undertaking a program of work to further strengthen these processes and support information sharing across the health system.

New incident management guide

The guide provides a brief overview of the incident management process and best practice approaches. It complements state and territory incident management policies, which provide more detailed information on local systems. Links to these policies are included in the guide.

Incident management guide

2021

Guide, user guide or guidelines

Australian sentinel events list version 2

Sentinel events are a subset of adverse patient safety events that are wholly preventable and result in serious harm to, or death of, a patient. They are the most serious incidents reported through state and territory incident reporting system.

The purpose of sentinel event reporting is to ensure public accountability and transparency and drive national improvements in patient safety.

Learn more about the Australian sentinel events list

Australian sentinel events (version 2.0)

1	Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death
2	Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death
3	Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death
4.	Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death
5.	Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death
6.	Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward
7.	Medication error resulting in serious harm or death
8.	Use of physical or mechanical restraint resulting in serious harm or death
9.	Discharge or release of an infant or child to an unauthorised person
10.	Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death

Specifications

The specifications for the ten national sentinel events were developed to provide clarity about what constitutes a sentinel event. This is intended to aid consistency in reporting.

The Commission has an expert group that oversees local or jurisdictional queries concerning classification of sentinel events. The group consists of clinical, policy and operational experts.

Australian Sentinel Events List (version 2) Specifications

2020

Publication, report or update

Development

The development of versions 2 of the Australian sentinel events list involved an environmental scan and literature review, targeted clinical consultation and broad public consultation.

Australian Sentinel Events List (version 2) Review summary

2020

Publication, report or update

History

The first version of the list was endorsed by Australian Health Ministers in 2002.

In April 2004, Australian health ministers determined that public hospitals should report on sentinel events at the national level. Since 2007, sentinel events have been reported by states and territories in the Productivity Commission’s annual Report on Government Services.

In 2017, the Commission undertook a review of the Australian sentinel events list on behalf of the states, territories and the Commonwealth and, the updated Australian sentinel events list was endorsed by Australian Health Ministers in December 2018.

For enquiries, please email indicators@safetyandquality.gov.au

Topics

Governance

Measures and indicators