DHF Annual Report 2009 - NT Health Digital Library - Northern ...

Sentinel Eventsdeath or serious harm to a client has occurred’.In 2004 Australian Health Ministers agreed to the national collection of sentinel event data. The DepartmentTable 13: Sentinel Events Per year and CategorySentinelEventCategoryNumber ofeventsNumber ofevents2008 - 2009 2009 - 2010Sentinel Event Type1 - - Procedures involving the wrong patient or body partresulting in death or major permanent loss of function2 - - Suicide of a patient in an inpatient unit3 - - Retained instruments or other material after surgeryrequiring re operation or further surgical procedure4 - - Intravascular gas embolism resulting on death orNeurological damage5 - - Haemolytic Blood transfusion reaction resulting fromABO incompatibility6 - - Medication error leading to the death of a patientreasonably believed to be due to incorrectadministration of drugs7 - 1 Maternal death or serious morbidity associated withlabour or delivery8 - - Infant discharged to wrong family or infant abduction9 14 27 Unexplained, unexpected death or serious illness ordisability reasonably believed to be preventableMuch of this measurement is undertaken in hospitals, and reporting of this data has three purposes: for transparency to provide important information to patients and consumers who are increasingly conscious to drive improvement by routinely providing information and timely performance feedback to cliniciansand manager.The World Health Organisation suggests that, in order to enhance patient safety, healthcare services need an‘increased ability to learn from mistakes, through better reporting systems, skilful investigation of incidents andresponsible sharing of data’.Sentinel event data is recorded and monitored centrally. All recommendations from investigations are monitoredthrough to completion and evidence is collected to demonstrate implementation.due to improved reporting.Department Health and Families 89