Sentinel Events to be reported to the Director, Office of Safety and Quality in Healthcare

Reportable Sentinel Events

Sentinel events are rare adverse events leading to serious harm or death that are caused by health care rather than patient illness. Sentinel events may signal serious breakdowns in health care systems. These events require indepth investigation to ascertain what happened and why, so preventive strategies can be implemented to reduce the occurrence of similar errors in the future. All hospitals and health services are required to report Sentinel events (see below) to the Director, Office of Safety and Quality in Healthcare, Department of Health (WA) within seven (7) working days of the incident occurring. The Nationally agreed list of Sentinel events includes the following:

• procedures involving the wrong patient or wrong body part;
• suicide of a patient in an inpatient unit;
• retained instruments or other material after surgery requiring re-operation or further surgical procedure;
• intravascular gas embolism resulting in death or neurological damage;
• haemolytic blood transfusion reaction resulting from ABO incompatibility;
• medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs;
• maternal death or serious morbidity associated with labour or delivery;
• infant discharged to wrong family or infant abduction; and
• other adverse event resulting in serious patient harm or death.

Dr Simon Towler
EXECUTIVE DIRECTOR
HEALTH POLICY AND CLINICAL REFORM

ATTACHMENTS:

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Sentinel Event Policy