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Assembly Bill 1 (AB1) was passed
during the 2002 18th Special Legislative Session, and
mandatory reporting of sentinel events was incorporated
into
Nevada Revised Statute (NRS) 439.800-890 and
Nevada Administrative Code (NAC) 439.900-920 (pdf).
Assembly Bill 59 (AB59) was passed during the 2005 73rd
Session of the Nevada Legislature, and codified
"facility acquired infection" as a reportable sentinel
event. Twenty-two other states in the U.S. have also
implemented, or are in the process of implementing, a
similar reporting system under their own state’s
legislative directive.
A “sentinel event” is
defined as an unexpected occurrence involving
facility-acquired infection, death or serious physical
or psychological injury or the risk thereof, including,
without limitation, any process variation for which a
recurrence would carry a significant chance of a serious
adverse outcome. The term includes loss of limb or
function (NRS
439.830) It is called a sentinel event because it
signals the need for immediate investigation and
response.
Mandatory reportable
sentinel events include events that have resulted in
an unanticipated death or major permanent loss of
function, not related to the natural course of the
patient’s illness or underlying condition.
NRS 439.805 identifies the
medical facilities required to report sentinel events:
- Acute Care Hospitals
including:
- Inpatient
Rehabilitation Hospitals
- Inpatient Psychiatric
Centers
- Ambulatory Surgery
Centers
- Independent Emergency
Room Centers
- Obstetric Centers
The Nevada
State Health Division is responsible for maintaining
the Sentinel Events Registry( NRS 439.840), which is
done by the Bureau of Health Care Quality & Compliance (HCQC).
The
Nevada
Hospital Association (NHA) and the
Nevada State Health Division
partnered, under the auspices of the Nevada Hospital
Association, to address the mandatory reporting
requirements of sentinel events. The NHA's Sentinel
Events Registry Work Group has worked diligently to meet
the requirements set forth in
NRS 439.800-890,
NAC 439.900-920 (pdf) and
AB59 (pdf). The Work Group developed uniform data
collection tools and instruction guide, for reporting
sentinel events and provided training for the medical
facilities required to report sentinel events.
NHA Sentinel Events
Registry Work Group:
-
Nevada
Hospital Association (NHA)
- Nevada State Health
Division- Bureau of Health Care
Quality & Compliance (HCQC)
- Quality Improvement and
Risk Managers from 9 Nevada Hospitals
- North: Carson-Tahoe
Hospital, Saint Mary's Med. Center and Renown Med.
Center.
- South: North Vista
Hospital, St. Rose Dominican Hospitals, Spring
Valley Hospital Medical Center, Sunrise Hospital &
Medical Center and University Medical Center.
- Rural: South Lyon Medical
Center.
The NHA Patient Safety
Committee has evolved out of the NHA Sentinel Events
Registry Work Group. The Work Group remains a
sub-committee of the Patient Safety Committee. |
