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– NEVADA –
Public and Private Policy
Medical Errors and Patient Safety

Definitions

The State of Nevada mandated reporting of ‘sentinel events’ beginning January 1, 2005. As defined by NRS 439.830, a ‘sentinel event’ means

" . . . 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."

With the exception of the phrase "facility-acquired infection" that was added in 2005 via Assembly Bill 59 [PDF], the definition is identical to the definition of ‘sentinel event’ that is used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Further refinement of this definition is not provided in Nevada statute.

Interestingly, a list of ‘Reportable Sentinel Events’ was provided in the Health Division of the Department of Human Resources 2004 draft of regulations [R118-04 §8(1b)]. That version of the regulations included specifications for 13 discrete reportable events. However, in the approval process, this list of proposed events was dropped, and no list of reportable sentinel events (as provided on the JCAHO website) were included in the regulations [Word Doc] that were adopted on November 4, 2004. The definition of "sentinel event" as defined above, served as the only interpretive guide to reporting medical facilities at that time.

However, in October 2005 Nevada provided a list of events in a Sentinel Event Report Guide [.doc File]. This guide includes a total of 30 distinct event definitions in Section I-12 of the guide.

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