All healthcare businesses licensed by the State of Nevada's Bureau of Health Care Quality and Compliance (HCQC) must participate (NRS)
Sentinel Events Registry in Health Care Settings
The Sentinel Events Registry (SER) Program tracks reportable sentinel events in healthcare facilities which includes hospitals, surgical center for ambulatory patients, independent center for emergency medical care, and obstetric centers (NRS 439.805) and since 2020, defined the types of healthcare facilities that must report sentinel events to the DPBH Sentinel Events Registry. (NRS 439.803)
Sentinel Event Definition
A sentinel event means an event included in Appendix A of "Serious Reportable Events in Healthcare--2011 Update: A Consensus Report," published by the National Quality Forum. If the publication described above is revised, the term "sentinel events" means the most current version of the list of serious reportable events published by the National Quality Forum as it exists on the effective date of the revision which is deemed to be:
(a) January 1 of the year following the publication of the revision if the revision is published on or after January 1 but before July 1 of the year in which the revision is published; or
(b) July 1 of the year following the publication of the revision if the revision is published on or after July 1 of the year in which the revision is published but before January 1 of the year after the revision is published.
If the National Quality Forum ceases to exist, the most current version of the list shall be deemed to be the last version of the publication in existence before the National Quality Forum ceased to exist (NRS 439.830). It is called a sentinel event because it signals the need for immediate investigation and response.
Mandatory Reporting of Sentinel Events
A person who is employed by a healthcare (includes medical) facility shall, within 24 hours after becoming aware of a sentinel event that occurred at the medical facility, notify the patient safety officer of the facility of the sentinel event; and report to the Division of public health within 13 or 14 days depending on whether the patient safety officer personally discovers or becomes aware of the sentinel event or the other medical employee at the medical facility discovers or becomes aware of the sentinel event (NRS 439.835).
Mandatory Investigation of Sentinel Event
A healthcare (includes medical) facility shall, upon reporting a sentinel event pursuant to NRS 439.835, conduct an investigation concerning the causes or contributing factors, or both, of the sentinel event and implement a plan to remedy the causes or contributing factors, or both, of the sentinel event (NRS 439.837).
The Nevada Division of Public and Behavioral Health is responsible for maintaining the Sentinel Events Registry (NRS 439.840),
which is done by the Office of Public Health Informatics and Epidemiology.
Mandatory Reporting of Any Not-Natural Death
A person who is employed by a healthcare (includes medical) facility shall, within 24 hours after becoming aware of a not-natural death that occurred at the healthcare facility, notify the patient safety officer of the facility of the sentinel event; and report to the Division of public health within 13 or 14 days depending on whether the patient safety officer personally discovers or becomes aware of the not natural death event or the other medical employee at the medical facility discovers or becomes aware of the sentinel event (NRS 439.837).
The Sentinel Events Registry holds monthly live question and answer periods using the Microsoft Teams platform. These are held every second Thursday of the month at 2:30pm.
To attend please send an email to the SER Administrator email address listed under 'Contact Us'. A meeting link will be provided via email reply.
Selected links to additional information regarding patient safety.
Sentinel Event Registry - Frequently Asked Questions
Important Information regarding Patient Safety Plans
Only hospitals, and ambulatory surgical centers are required to submit a copy of their Patient Safety Plan (without staff names).
Annual Summary Report filing Patient Safety Plan's MUST BE
Americans with Disabilities Act (ADA) COMPLIANT or it will be REJECTED. ADA Americans with Disabilities Act
Annual Summary Report filing is pen from January 1 to March 1 of each year
The next reporting period for the Annual Summary Report ends
March 1, 2025, covering patient safety activities during the calendar year
2024.
What is expected to be reported? (Even if no sentinel event occurred):
a)
Any sentinel events that occurred at the facility (counts only),
b)
How often patient safety meetings are held, who attends, and if
attendance is mandatory.
c)
Only medical facilities need to upload their Patient Safety Plans that are
Americans with Disabilities Act (ADA) complaint. Please have all staff names
redacted.