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.'
11 July 2007
Further information: Ms Jenny Hargreaves AIHW,
tel. 02 6244 1121, mob. 0407 012 520, or Dr Diana Horvath AO,
ACSQHC, tel. 02 9263 3616.
For media copies of the report: Publications
Officer, AIHW, tel. 61 2 6244 1032.
Availability: Check the AIHW Publications
Catalogue for the availability of Sentinel events in
Australian public hospitals 2004-2005.