Sentinel events


What is a sentinel event?

‘Sentinel event’ refers to a subset of serious clinical incidents that have caused or could have caused serious harm or death of a patient. It refers to preventable occurrences involving physical or psychological injury, or risk thereof. Sentinel events are 10 specific types of clinical incidents:

  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

Guides

Annual sentinel event reports

Earlier sentinel event reports are available on request.

More information

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

Last reviewed: 27-07-2021
Produced by

Patient Safety Surveillance Unit