Page 979 - Week 03 - Thursday, 30 March 2006
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(1) What were the nine sentinel events recorded in 2004-05 as stated by the Minister in a response to a question taken on notice to the Annual and Financial Reports 2004-05 hearings;
(2) How many sentinel events have occurred to date this financial year and what exactly was the sentinel event on each occasion;
(3) On how many occasions since 2001-02 to the current date have sentinel events occurred such as (a) procedures involving the wrong patient or body part, (b) suicide of a patient in an in-patient facility, (c) retained instruments or other material after surgery requiring reoperation, (d) intravascular gas embolus resulting in death or neurological injury, (e) medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs and (f) maternal death or serious morbidity associated with labour or delivery;
(4) How is it that an infant can be discharged to the wrong family.
Mr Corbell: The answer to the member’s question is as follows:
(1) The sentinel events reported in 2004-05 comprised:
• Suicide or attempted suicide – 1 attempted suicide;
• Retained instruments or other material after surgery requiring re-operation or further surgical procedure – 1 retained portion of the laparoscopic banding wire and 2 retained portion of guide wire after insertion of Peripherally Inserted Central Catheters (PICCs);
• Medication error leading to death of a patient reasonably believed to be due to incorrect administration of drugs – 2, and
• Maternal death or serious morbidity associated with labour or delivery – 1 patient required hysterectomy following a massive antepartum haemorrhage, 2 patients required hysterectomy following massive postpartum haemorrhages.
(2) There have been 4 sentinel events reported to date, this financial year and comprise; Retained instruments or other material after surgery requiring re-operation or further surgical procedure (2 incidents involving retained pleurocaths), and Maternal death or serious morbidity associated with labor or delivery (2 hysterectomies required to control post partum haemorrhage).
(3) ACT Health implemented a policy on the mandatory reporting of sentinel events in 2004. ACT Health was not measuring sentinel events prior to the introduction of the policy.
(4) ACT Health has not had any reported events where an infant has been discharged to the wrong family. From the literature it appears to occur due to systems failures that are usually associated around identification tags.
Health—SIDS and Kids
(Question No 943)
Mr Smyth asked the Minister for Health, upon notice, on 16 February 2006:
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