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An adverse patient safety event is an event that results in unnecessary or avoidable harm to a patient.

The Australian Commission on Safety and Quality in Healthcare (ACSQHC) has updated the 10 national sentinel event categories. The updated categories came into effect on 1 July 2019.

In addition to the 10 national categories, Victoria has an 11th category: All other adverse patient safety events resulting in serious harm or death.

Victorian health services must report for all 11 categories.

We have developed a Victorian Sentinel event guide to help health services identify and manage sentinel events.

Australian sentinel events list (version 2)

1

Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death

2

Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death

3

Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death

4

Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death

5

Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death

6

Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward

7

Medication error resulting in serious harm or death

8

Use of physical or mechanical restraint resulting in serious harm or death

9

Discharge or release of an infant or child to an unauthorised person

10

Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death

11

All other adverse patient safety events resulting in serious harm or death

Unsure if you need to report?

Contact our incident response team on (03) 9096 1546 or email sentinel.events@safercare.vic.gov.au

Resources on what to report

Page last updated: 28 Jun 2019

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