NV.gov
Q1 What is the Sentinel Events Registry?
What is the Research Electronic Capture System (REDCaps)?
REDCaps is the technology currently used to enter SER data.
What is a Sentinel Event?
“In plain terms a sentinel event is anything that should never happen in a healthcare setting.”
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.
Also see: Does my occurrence qualify as a Sentinel Event - A Decision Tree
Who reports Sentinel Events?
The SER reporting system allows three active data entry roles: Patient Safety Officer (PSO), Designated Reporters (DR) maximum of 2 Administrator (read only) Once the appropriate accounts/users have been established, then a new contact form needs to be completed. |
When there is a change in staff related to Sentinel Event Reporting?
The following information is needed to establish a sentinel events reporting account.
1. Name
2. Your email address
3. Your phone number
4. Facility Name
5. HCQC State of Nevada license number
6. Your role (PSO, DR, or Admin)
7. Professional designation/staff title
Once your account is created, you will receive an email to set your account password.
In addition, see question 11 on how to complete a new "Sentinel Event Contact Form” reflecting the new staff, along with effective dates for those accounts to be suspended.
What important timelines do I need to know?
1 day (24 hours) - A person who is employed by a medical facility shall 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.
7 days - Not later than 7 days after discovering or becoming aware of a sentinel event that occurred at the medical facility, provide notice of that fact to each patient who was involved in that sentinel event. (NRS 439.855)
13 or 14 days - Report to the Division of public health, 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)
45 Days -Within
45 days of submitting the Part 1 form, the facility is
required
to submit the Part 2 form, which includes the facility’s quality improvement
committee describing key elements of the events, the circumstances surrounding
their occurrence, the corrective actions that have been taken or proposed to
prevent a recurrence, and methods for communicating the event to the patient’s
family members or significant other(s).
Calendar Year - The Annual Summary Report is due by the close of business on March 1 of each year, for the proceeding years’ patient safety activities at your facility. (NRS 439.843)
What if I represent more than one facility?
One person, one facility, one account.
If you represent more than one facility you will have more than one account. Each account’s username follows this pattern, firstname_lastname_licensenumber.
How do I enter an individual sentinel event into the REDCaps SER reporting system?
REDCap SER Reporting system login:
https://dpbhrdc.nv.gov/redcap/
Enter your username and your password.
Blue Arrow to view Events Submitted
Red Arrow to add a new event or to update an existing event.
Blue arrow to update/edit an existing record, or
Red arrow to create a new event.
Red rectangle added to help locate gray radio button to click.
Red arrow points to Sentinel Event Report part 1 row and the Event 1 column.
Clicking opens the data entry Report form 1
Gray button to initiate a new entry.
Yellow button indicates data entered with status for Registrar to verify.
Green button indicates data entry complete and Registrar verified.
Red button indicates data entry not complete.
At the bottom of Report form 1 and Report form 2 Always select “Unverified”.
Do not lock the record.
Select Save & Exit Form when you have finished completing the form.
This view shows after Report part 1 was entered but before Registrar verification and before Report part 2 entered.
This record view means the SER event has parts 1 and 2 completed with the registrar having verified correct data entry.
No further action on this record.
Q 10 How do I enter the Annual Sentinel Events Summary Report into the REDCaps SER reporting system?
REDCap SER Reporting system login:
https://dpbhrdc.nv.gov/redcap/
Enter your username and your password.
Select the row for your facility licence number (ID).
Blue arrow first gray button from left to enter new Contact Form.
Red arrow gray button to enter the Annual Sentinel Event Summary Report. Always select the most recent preceding year.
How do I Update the Contact Form when there are changes in reporting staff?
After completing all the new data, including new staff, and re-entering staff that are continuing in their role.
Follow Question A 9h and A 9i to complete the record status and save the form.
Where can I learn about Patient Safety?
Thanks for asking! Consider the link below as a start.
Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis