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.
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 each jurisdiction’s incident reporting system. The intent is not to measure episodes that do not end in death or ongoing morbidity.
The national sentinel events (v2.0) are listed below:
|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|
|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|
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.
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.
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.
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