Sentinel Events reporting
Sentinel Events are preventable adverse events that result in death or serious harm to a patient. In 2002, Australian States and Territories agreed to contribute to a set of eight core National Sentinel Events (NSEs) which were reported nationally between 2004 and June 2019. Public reporting of these events is an opportunity for jurisdictions to share learnings, and to reduce the risk of their recurrence. It is important to note that Sentinel Events occur infrequently and are often due to an issue with the way a system or process works in our health care system.
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.
Australian States and Territories have historically interpreted and reported these Sentinel Events differently. NSW has adopted a broad interpretation of these events and therefore comparison of the data across states requires caution.
Revised Australian Sentinel Events (ASE)
A revised ASE list was endorsed by Australian Health Ministers in December 2018. Commencing on 1 July 2019, NSW Health required all ten ASEs on the revised list to be notified to the Ministry of Health via a Reportable Incident Brief (RIB) and undergo a SAER. To be classified as a sentinel event, a strict set of criteria need to be met:
- The event should not have occurred where preventive barriers are available
- The event is easily recognised and clearly defined
- There is evidence the event has occurred in the past.
Data on Sentinel Events is reported in the annual Report on Government Services (RoGS). At present, Sentinel Event data is available to 2021-22. Data for 2022-23 will be published in the next RoGS release scheduled for early 2025.
In 2021-22, a total of 64 sentinel events were reported across all Australian jurisdictions (Table 14a). This represents a 22 per cent reduction compared with the preceding reporting period 2020-21. NSW reported 12 of the 64 sentinel events (Table 14b).
An overall decrease in medication related sentinel events is noted within NSW and across all Australian jurisdictions when compared to the previous reporting period 2020-21. NSW reported a single medication related error across 2021-22, a reduction from 11 in the previous reporting period.
Nationally there were 16 suspected suicides in psychiatric units/wards reported in 2021-22, a reduction from 18 the previous year. In NSW this has increased from 4 in 2020-21 to 7 in 2021-22.
Table 14a: Australian Sentinel Events - all Australian Jurisdictions
| Selected sentinel event | 2019-20 | 2020-21 | 2021-22 | |||
| 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 | |||
Table 14b: Australian Sentinel Events - NSW
| Selected sentinel event | 2019-20 | 2020-21 | 2021-22 | |||
| 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 | |||
Caveats
Nil or rounded to zero. Australian health ministers agreed version 2 of the Australian sentinel events list in December 2018. All jurisdictions implemented these categories on 1 July 2019. Sentinel event data for prior years, reported against the previous version of the Australian sentinel events list, are available in earlier editions of RoGs. Data are comparable (subject to caveats) across jurisdictions and over time. Data are complete (subject to caveats) for the current reporting period. Source: Report on Government Services 2023, Part E, Section 12: Released on 31 January 2024 12 Public hospitals - Report on Government Services Productivity Commission (pc.gov.au)