Reportable sentinel events

Sentinel events to be reported to the Director, Office of Safety and Quality in Healthcare are:

• Procedures involving the wrong patient or body part
• Suicide of a patient in an inpatient unit (Under the Mental Health Act, Mental Health services are required to report to the Chief Psychiatrist episodes of unexpected death. See Operational Circular OP 2061/06 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 or serious morbidity associated with labour or delivery
• Infant discharged to wrong family or infant abduction
• Other adverse event resulting in serious patient harm or death