Sentinel event program
What is a sentinel event?
Sentinel events are relatively infrequent, clear-cut events that occur independently of a patient's condition, commonly reflect hospital (or agency) system and process deficiencies; and result in unnecessary outcomes for patients.
Reportable sentinel events
There are eight national defined Sentinel events:
- procedures involving the wrong patient or body part resulting in death or major permanent loss of function
- suicide in an inpatient unit
- retained instruments or other material after surgery requiring re-operation or further surgical procedure
- intravascular gas embolism resulting in death or neurological damage
- haemolytic blood transfusion reaction resulting from ABO incompatibility
- medication error leading to the death of patient reasonably believed to be due to incorrect administration of drugs
- maternal death or serious morbidity associated with labour or delivery
- infant discharged to wrong family.
Episodes of suicide that are reportable under the Mental Health Act (1986) should continue to be reported to the Chief Psychiatrist.
Notifying and reporting sentinel events: All health services and agencies that identify an incident that reflects a national sentinel event definition are required to report the incident to the Sentinel event program.
The category ‘other catastrophic event’ has previously been unique to the Victorian framework since inception of the Sentinel event program in 2001. With the introduction of the Victorian health incident management system (VHIMS) the ‘other catastrophic’ category will be replaced by clinical incidents with an incident severity rating (ISR) of 1.
If a health service identifies an ISR 1 clinical incident they are requested to review the event. This review is to determine whether the incident outcome was directly related to the patient’s condition/illness or due to a breakdown in health service systems or processes. If the review identifies that a breakdown in system or process issues contributed to the incident outcome, the incident is to be reported to the Sentinel event program.
This policy change replaces the ‘other catastrophic event’ category. Over time, this will enable a greater understanding of the range frequency of events previously categorised as ‘other’.
Irrespective of the transition to the new incident management framework, Victoria will continue to report nationally, as required, against the eight defined sentinel events
Sentinel event program annual reports
The Department of Health wishes to acknowledge individual clinicians and health services who have contributed to the Sentinel event program.
Sentinel event program - Annual report 2011-12 and 2012-13
The Sentinel event program annual report 2011-12 and 2012-13 provides a summary of the program and outlines identified system issues. It also provides examples of sentinel events that have occurred and the risk reduction action plans health services have developed to support changes to the system to ensure quality, safe patient care
See also previous annual reports.