National Sentinel Event (NSE)

Sentinel Events are adverse events that result in death or serious harm to a patient and are preventable. In 2002, Australian states and territories agreed to contribute to a set of eight core Sentinel Events which have been reported nationally since 2004. Public reporting of these events was an opportunity for jurisdictions to share learnings, and to reduce the risk of their recurrence. It is important to note that these Sentinel Events occur infrequently, and, are often due to an issue with the way a system or process works in our health care system.

The eight (8) agreed Sentinel Events during the reporting period are:

  1. Procedures involving the wrong patient or body part resulting in death or major permanent loss of function;
  2. Suicide of a patient in an inpatient unit;
  3. Retained instruments or other material after surgery requiring re-operation or further surgical procedure;
  4. Intravascular gas embolism resulting in death or neurological damage;
  5. Haemolytic blood transfusion reaction resulting from ABO incompatibility;
  6. Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs;
  7. Maternal death associated with pregnancy, birth and the puerperium; and
  8. Infant discharged to the wrong family.

It is important to note that Australian States and Territories have historically interpreted and reported these Sentinel Events differently. NSW has adopted a broad interpretation and comparison of these events and, as a result, caution is required in interpreting this data.

From 2007, Sentinel Events have been reported by each Australian jurisdiction for inclusion in the Productivity Commission's Report on Government Services (ROGS). The ROGS provides information on the effectiveness and efficiency of government services in Australia and contains annual data on the equity, efficiency, and cost effectiveness of government services. NSW Sentinel Event data is displayed at Table 14.

Suicide of a patient in an inpatient unit

There has been a decrease in inpatient suicides from 7 in 2017/18 to 4 in 2018/19. It is important to note that the NSW definition of events in this category is broader than the Australian Commission for Safety and Quality in Healthcare's definition. NSW Health includes patients on approved leave and those who have absconded from care.

Retained material

There has been an increase in retained instruments or other material requiring re-operation or further surgical procedure from 7 in 2017/18 to 12 in 2018/19.

Medication Safety

Since 2013/14, NSW public hospitals continue to take action to improve medication safety with support from the CEC by establishing and implementing dedicated improvement programs focussed on high-risk medicines. High risk medicines are those that have a high risk of causing injury or harm if they are used or misused in error. NSW Health is also improving patient safety through investment in Electronic Medication Management (eMeds) systems across NSW hospitals. eMeds systems help to improve patient safety by reducing medication incidents and adverse events.

Incidents involving medication error resulting in death due to incorrect administration of drugs has increased by one, from 3 in 2017/18 to 4 in 2018/19.

Maternal deaths

There were 3 maternal deaths associated with pregnancy, birth or the puerperium in the 2018/19 reporting period. Note that the definition was altered in the 2014/15 reporting period to include both the antenatal and post-natal periods, whereas the previous definition included delivery only. Subsequently, data relating to the 2014/15 and 2015/16 financial years are not comparable to any results previously published.

Table 14: NSW selected sentinel events (*)

Selected sentinel event2014-152015-162016-172017-182018-19
Procedures involving the wrong patient or body part resulting in death or major permanent loss of function 0 3 0 0 0
Suicide of a patient in an inpatient unit 15 9 4 7 4
Retained instruments or other material after surgery requiring re-operation or further surgical procedure 20 9 8 7 12
Intravascular gas embolism resulting in death or neurological damage 3 3 0 3 0
Haemolytic blood transfusion reaction resulting from ABO (blood group) incompatibility 0 0 0 0 0
Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs 3 4 2 3 4
Maternal death associated with pregnancy, birth or the puerperium 4 6 4 0 3
Infant discharged to the wrong family 0 0 0 0 0
Total4534182023

Caveats
*Sentinel event definitions can vary across jurisdictions, and are therefore not comparable. Data for reporting periods prior to 2016-17 include events that occurred in private hospitals and day procedure centres and are therefore not comparable with data for 2016-17
**Data are sourced from the NSW Maternal and Perinatal Mortality Review Committee. Data for all prior years included in the table have been updated to reflect the modified definition, and are therefore not comparable to results published in the 2014 Report and prior versions.

Source: Report on Government Services 2021, Part E, Section 12 available at https://www.pc.gov.au/research/ongoing/report-on-government-services/2021/health/public-hospitals

In 2017, the Australian Commission on Safety and Quality in Healthcare undertook a review of the Sentinel Events on behalf of states and territories and the Commonwealth. From 1 July 2019, a revised list of events will be collected and will be reported in the ROGS in January each year, and on the CEC's website.

Table 15: National Selected Sentinel Events*

Selected sentinel event2014-152015-162016-172017-182018-19
Procedures involving the wrong patient or body part resulting in death or major permanent loss of function 1 5 1 1 1
Suicide of a patient in an inpatient unit 30 28 20 24 17
Retained instruments or other material after surgery requiring re-operation or further surgical procedure 35 26 23 28 28
Intravascular gas embolism resulting in death or neurological damage 5 4 3 3 1
Haemolytic blood transfusion reaction resulting from ABO (blood group) incompatibility 1 2 0 2 0
Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs 14 7 10 16 12
Maternal death associated with pregnancy, birth or the puerperium 9 9 7 2 6
Infant discharged to the wrong family 0 0 0 1 0
Total10182658065

Caveats
(a) Sentinel events definitions can vary across jurisdictions and are therefore not comparable. The total includes sentinel events for the ACT which are not reported in the 8 sub categories of sentinel events due to confidentiality issues

Source: Report on Government Services 2021, Section 12, available at https://www.pc.gov.au/research/ongoing/report-on-government-services/2021/health/public-hospitals

Revised Australian Sentinel Event List (ASE)

A revised Australian Sentinel Events (ASE) list was endorsed by Australian Health Ministers in December 2018. NSW Health requires all ASEs on the revised list to be notified to the Ministry of Health via a RIB from 1 July 2019 and investigated accordingly. The revised ASE list identifies ten Sentinel Events, while the previous list identified eight. Maternal death or serious morbidity associated with labour and delivery, and intravascular gas embolism resulting in death or neurological damage, have been removed.

The Australian Sentinel Event list (version 2) 2018 includes:

  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 (New);
  9. Discharge or release of an infant or child to an unauthorised person; and
  10. Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death (New).