Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward
Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm of death Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death Table 14a: Australian Sentinel Events - all Australian Jurisdictions Selected sentinel event Sentinel event data for prior years, reported against the previous version of the sentinel events list, are available in earlier editions of ROGS. NSW accounted for 19 of these events (Table 14b). In 2020-21, a total of 82 sentinel events reported across all Australian jurisdictions (Table 14a). Data for 2021-22 will be published in the next ROGS release in early 2024. At present, Sentinel Event data is available for 2020-21. Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death (New)ĭata on Sentinel Events is reported in the annual Report on Government Services (ROGS).Discharge or release of an infant or child to an unauthorised person.Use of physical or mechanical restraint resulting in serious harm or death (New).Medication error resulting in serious harm or death.Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward.Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death.Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death.Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death.Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death.Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death.The Sentinel Events of Maternal death or serious morbidity associated with labour and delivery, and intravascular gas embolism resulting in death or neurological damage, have been removed. The revised ASE list identifies ten Sentinel Events, while the previous list identified eight. Commencing on 1 July 2019, NSW Health required all ASEs on the revised list to be notified to the Ministry of Health via a Reportable Incident Brief (RIB) and to be reviewed accordingly. Revised Australian Sentinel Events (ASE) listĪ revised ASE list was endorsed by Australian Health Ministers in December 2018.
NSW has adopted a broad interpretation of these events and therefore comparison of the data across states requires caution. Sentinel Event data is displayed in Table 1.Īustralian States and Territories have historically interpreted and reported these Sentinel Events differently. 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. 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.įrom 2007, Sentinel Events have been reported by each Australian jurisdiction for inclusion in the Productivity Commission's Report on Government Services (ROGS). Public reporting of these events is an opportunity for jurisdictions to share learnings, and to reduce the risk of their recurrence.
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. Sentinel Events are preventable adverse events that result in death or serious harm to a patient.
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