Sentinel Events

Know this for the GSET interview

This is an adverse event that was preventable and resulted in serious morbidity or mortality to a patient.

Open Disclosure must happen. Reported to hospital risk management / safety and quality Reported to Safer Care Victoria

Discuss at unit meeting and M&M

These include:

• Wrong side
• Suicide
• Retained material
• Gas embolism
• Haemolytic Blood transfusion reaction
• Medication error leading to serious harm or death
• Infant discharged to wrong family
• Maternal death