Sentinel events in public hospitals 2004-05 is the first joint publication of the Australian Commission for Safety and Quality in Health Care and the Australian Institute of Health and Welfare. The report presents data on the number and nature of sentinel events occurring in Australian hospitals over the period 1 July 2004 to 30 June 2005 and the factors that contributed to these serious adverse events. This is the first report of its kind to draw together data on sentinel events from all states and territories and paves the way for national reporting of health care safety and quality information to inform policy responses and initiatives.