Sentinel Event program makes healthcare in WA even safer

The WA Sentinel Events Report 2005 – 2006 shows a significant reduction over the past year in the number of errors involving surgical procedures thanks to new policies introduced as part of the Sentinel Events Program.

Chief Medical Officer, Dr Simon Towler, said the number of sentinel events occurring in the eight nationally agreed categories had almost halved over the past year, from 20 to 11, while the total number of sentinel events fell from 43 to 42.

“This decrease is due to a number of effective strategies put in place such as the Correct Patient, Correct Site, Correct Procedure protocol and the ongoing vigilance of health care professionals to prevent these types of incidents occurring,” Dr Towler said.

“While this represents just 0.004 per cent of total admissions to public and private hospitals, any incident causing harm to patients is unacceptable.”

Dr Towler said that the contributing factors in the majority of incidents involved multiple system issues rather than an individual’s performance or behaviour.

“The delivery of health care in recent times has become more complex, with patient care involving the input of many people and the use of highly technical equipment and treatments,” he said.

 “It is not surprising that sometimes things go wrong, but fortunately in most cases the patient is unharmed. 

“When things do go wrong it is devastating for everyone, particularly the patient and their family, and it is important that we learn from these mistakes and do everything we can to minimise the chance of it happening again.

“Each sentinel event is thoroughly investigated to determine the causes and contributing factors, and prevention strategies are put in place to reduce the occurrence of similar errors in the future.

“One of the new initiatives in WA public hospitals this year has been the introduction of a national inpatient medication chart which will reduce the risk of drug errors.”

Dr Towler said the WA public should be reassured that the Sentinel Event Program was one of many processes in place designed to improve patient safety in our hospitals.