Sentinel Event Registry in Health Care Settings
The Sentinel Event Registry (SER) Program tracks reportable sentinel events in medical facilities which includes hospitals, surgical center for ambulatory patients, independent center for emergency medical care, and obstetric centers (NRS 439.805).
Senate Bill 457 (2019 Legislative Session) This bill was passed during Nevada’s 80th Legislative Session (Spring 2019). The bill further defined the types of health facilities that must report sentinel events to the DPBH. The legislation amended (NRS 439.803) to expand the Sentinel Event Registry participation from “Medical facility,” to “Health facility” and added the reporting requirement of any non-natural death that occurs in the facility. Some aspects of SB457 are not a part of the Sentinel Events Registry.
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 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 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 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).
Recording of live SER Webinar February 2022
Sentinel Event Reporting Guidance