Sentinel events

What is a sentinel event?

A sentinel event refers to unexpected occurrences involving death or serious physical or psychological injury or risk thereof. Sentinel events represent 8 specific types of clinical incident that were endorsed by Australian Health Ministers in 2004. They are:

  • procedures involving the wrong patient or body part resulting in death or major permanent loss of function
  • suicide of a patient in an inpatient unit (or while on leave). Note: mental health services are also required to report to the Chief Psychiatrist episodes of unexpected death. See OD 0588/15 Mandatory Reporting of Notifiable Incidents to the Chief Psychiatrist (external site) for further information
  • 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 associated with pregnancy, birth or the puerperium – note: maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes
  • infant discharged to wrong family or infant abduction.

Further description of the 8 sentinel event categories can be found in the Clinical Incident Management Policy (external site).

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). 




Annual sentinel event reports

See previous sentinel event reports.

More information

Patient Safety Surveillance Unit
Phone: 9222 2238

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Patient Safety Surveillance Unit