In February 2021, Better Safer Care Victoria provided a report on “sentinel events”; incidents in which a person receiving healthcare died or was seriously harmed. Put another way, a sentinel event is a particular type of serious incident that is wholly preventable and has caused serious harm to, or the death of, a patient.
You can download the Better Safer Care Victoria, “Supporting patient safety: learning from sentinel events” annual report 2019-20 here.
Consider this personal experience
About a week after my partner Sophie gave birth to our twins, she was readmitted to hospital. After being up and walking around for a few days she was ordered back to the hospital bed to recover from an infection. After a few hours on the ward, her room curtain was whipped back by a busy nurse.
Nurse: We need to give you an injection, she declared.
Soph: Oh, a nurse just came around a moment ago, what’s this for?
Nurse: Because you’ve been in bed, we need to inject a blood thinner to stop you getting a clot.
We were confused.
Soph: But I’ve been up and walking around until earlier today, Sophie protested.
Nurse: Well, I’ve been ordered to give you this injection, so that’s what we’ll do.
Just as the nurse approach Sophie’s arm, syringe at the ready, a small voice at the door broke the awkward silence.
“Psst. Wrong patient”.
The voice grew more confident at the edge of the room; “you’ve got the wrong patient, the wrong room. This one doesn’t need clexane”.
And in a flash, the nurse vanished with the syringe, bound for the right room, the right patient.
At the time we laughed, happy to have some light relief from the weight of Sophie’s health and the worry about our twins in the humidicribs down the hall.
Some patients aren’t so lucky. Amongst millions of procedures and treatments performed in a world class health care system, near misses, serious errors and tragedies occur.
Health services obligations to report on and investigate sentinel events
Reporting on sentinel events and investigating them is critical to continued learning and improvement in the health system.
As a result, health services have an obligation to report the most serious cases of patient harm and death that have resulted from adverse patient safety events, and make sure they are properly reviewed.
Serious harm is considered to have occurred when, as a result of an incident, the patient has:
- required life-saving surgical or medical intervention;
- received a shortened life expectancy;
- experienced permanent or long-term physical harm, or permanent or long-term loss of function.
This obligation extends to a wide range of health services, which include:
- Ambulance Victoria;
- Bush nursing centres;
- Forensicare (Thomas Embling Hospital);
- Public sector residential aged care facilities;
- Hospital in the home services; and
- Private day surgery facilities.
What does the Better Safer Care Victoria report show?
The report shows that the number of sentinel events reported in Victoria increased in the most recent 12-month period. However, it is difficult to say whether this is because the number of errors is increasing or because hospitals are becoming better at reporting and investigating sentinel events.
In 2019-2020 in Victoria, there were 186 sentinel events reported. It should be noted that it is widely understood that this number is far less than the actual number of events which occurred. Further, work is being done to encourage reporting as a patient safety and educational tool.
The top 3 most common errors in 2019-2020
The top common medical errors determined in the report were related to:
- women and babies during pregnancy, labour or the post-natal period (19%);
- patient falls (13%);
- medication errors (11%).
The most widely known medical error occurred only twice in Victoria in 2019-20. On two occasions a foreign body was left in a patient after surgery, resulting in serious injury or death.
This statistic is perhaps a relief to anyone assuming that this was a common error, but frightening to think that the error could occur at all.
Significant concerns related to mental illness events
On 8 occasions, a patient in an acute psychiatric unit or ward suicided. Sadly, given the increase in reported mental illness in the Victorian community in the last 12 months (with increases due to the pressures of COVID-19) and the well-reported significant pressures on the mental health system, the number of sentinel events involving mental health facilities is likely to increase in the next reporting period.
Reporting and investigating incidents where patients are harmed or killed is a critical piece of the patient safety jigsaw. Patients should be entitled to know what went wrong and why during their medical treatment. Likewise, the public are entitled to expect that while mistakes in a large and sophisticated health system will occasionally occur, that those mistakes are learned from, and that we are safer as a result.
Claims for compensation by injured patients (medical negligence claims) are a blunt instrument for effecting change in the health system. They cannot effectively be a force for systemic change without a health system which encourages open disclosure and improvement, and without health regulators who are prepared to investigate errors in order to adequately protect the public.