Australian sentinel events list

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.

Australian sentinel events list version 2

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

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

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. 

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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.

Further information

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