Studying sentinel events means learning from mistakes

A new report, released today by the Australian Institute of Health and Welfare (AIHW), and the Australian Commission on Safety and Quality in Health Care (the Commission), examines sentinel events that occurred in Australian public hospitals in 2004-05.Ms Jenny Hargreaves, Senior Executive in the Institute's Economics and Health Services Group explained sentinel events as relatively rare events which may potentially, or actually, contribute to patient harm.

Examples of sentinel events include procedures involving the wrong patient or body part; swabs or instruments left behind after surgery requiring re-operation; and maternal death during delivery.

These accidental events are now being reported and analysed, to look for ways of making the complex world of hospital care safer for patients.' Ms Hargreaves said.

In 2004-05 there were 130 reported sentinel events in Australia. As these reflect the early days of reporting, the numbers reported may grow as systems that enable effective reporting in hospitals develop,' she said.

The most common sentinel events reported were procedures involving the wrong patient or body part - 53 (41%).

The most common factors leading to these events were problems with, or breakdown in, rules, policies and procedures.

The report, Sentinel events in Australian public hospitals 2004-2005, is the first joint report between the AIHW and the Commission. It follows the progressive public reporting by states and territories of adverse events in their public hospitals.

Dr Diana Horvath AO, Chief Executive of the Commission said 'Neither health professionals nor consumers want patients harmed, but we all know that mistakes can happen. What we want is to minimise the harm that these cause. Sentinel events are an opportunity to consider where we can focus our efforts.'


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