Sentinel events

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.

Further description of the 10 sentinel event categories can be found in the Clinical Incident Management Guideline (PDF 2MB).

In WA, sentinel events are categorised as Severity Assessment Code 1 (SAC 1) clinical incidents. The reporting of SAC 1 clinical incidents is mandatory for:

• public hospitals
• all private licensed health care facilities
• nongovernment organisations (in accordance with their license or contract with WA Health).

Resources

Policies

• Clinical Incident Management Policy 2019
• Reporting of Notifiable Incidents to the Chief Psychiatrist – Public Mental Health Services (external site)
• Reporting of Notifiable Incidents to the Chief Psychiatrist – Private Hospitals and NGOs (external site)

Guides

• Severity Assessment Code (SAC) Summary Table (PDF 500KB)

Reporting to Independent Hospital Pricing Authority (IHPA)

The WA Department of Health is required to report Sentinel Events occurring in public hospitals with a patient outcome of serious harm or death to the Independent Hospital Pricing Authority (IHPA) (external site). Any public hospital episode of care that includes a Sentinel Event incident occurring on or after 1 July 2017 does not receive national funding. For further information see the IHPA Pricing Framework for Australian Public Hospital Services.

Report to Productivity Commission Report on Government Services (ROGS)

The WA Department of Health also reports Sentinel Events with a patient outcome of serious harm or death nationally to the Productivity Commission Report on Government Services (ROGS) (external site).

More information

Patient Safety and Surveillance Unit
Email: pssu@health.wa.gov.au