Studying sentinel events means learning from mistakes

A new report, of the Australian Institute of Health and Welfare (AIHW), and the Australian Commission on Safety and Quality in Health Care (the Commission), examines sentinel events- which may potentially, or actually, contribute to patient harm- that occurred in Australian public hospitals in 2004-05.

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.

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