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Reporting And Data

Surgery or Procedure on Wrong Site (Sentinel Event 1A)

Latest Update: August 11, 2020
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Reporting Information

Facilities must report any surgery or other invasive procedure performed on the wrong site, defined as any surgery or other invasive procedure performed on a body part or site that is not consistent with the correctly documented informed consent for that patient. Surgery or other invasive procedure includes, but is not limited to, endoscopies, lens implants, lesion removal, injection into joints. Excludes emergent situations that occur in the course of surgery or other invasive procedure and/or whose exigency precludes obtaining informed consent. Intended to capture instances of: surgery or other invasive procedure on the right body part but on the wrong location/site on the body; e.g., left/right (appendages/organs), wrong digit, level (spine), stent placed in wrong iliac artery, steroid injection into wrong knee, biopsy of wrong mole, burr hole on wrong side of skull; delivery of fluoroscopy or radiotherapy to the wrong region of the body; use of incorrectly placed vascular catheters; use of incorrectly placed tubes (for example, feeding tubes placed in the lung or ventilation tubes passed into the esophagus).

Responsible Party

Who Must Report?

State of Nevada Healthcare License types now required by SB457 from the 2019 legislative session, and implemented as of 1/1/20, to report to the Sentinel Events Registry include the following:

  • ADA - FACILITY FOR THE TREATMENT OF ABUSE OF ALCOHOL OR DRUGS
  • ADC -¬†FACILITY FOR THE CARE OF ADULTS DURING THE DAY
  • AGC - RESIDENTIAL FACILITY FOR GROUPS
  • ASC - SURGICAL CENTER FOR AMBULATORY PATIENTS
  • BPR - BUSINESS THAT PROVIDES REFERRALS TO RFFG
  • CTC - COMMUNITY TRIAGE CENTER
  • ESRD - FACILITY FOR THE TREATMENT OF IRREVERSIBLE RENAL DISEASE
  • HBR - AGENCY TO PROVIDE NURSING IN THE HOME - BRANCH OFFICE
  • HFS - FACILITY FOR HOSPICE CARE
  • HHA - AGENCY TO PROVIDE NURSING IN THE HOME
  • HIC - HOME FOR INDIVIDUAL RESIDENTIAL CARE
  • HOS - HOSPITAL
  • HPC - HOSPICE CARE - PROGRAM OF CARE
  • HSB - AGENCY TO PROVIDE NURSING IN THE HOME - SUB UNIT
  • HWH - HALF-WAY HOUSE FOR RECOVERING ALCOHOL AND DRUG ABUSERS
  • ICE - INDEPENDENT CENTER FOR EMERGENCY MEDICAL CARE
  • ICF - FACILITY FOR INTERMEDIATE CARE
  • IMR - FACILITY FOR INTERMEDIATE CARE/IID
  • MDX - FACILITY FOR MODIFIED MEDICAL DETOXIFICATION
  • NSP - NURSING POOL
  • NTC - FACILITY FOR TREATMENT WITH NARCOTICS
  • OPF - OUTPATIENT FACILITY
  • PCO - PERSONAL CARE AGENCY THAT IS ALSO ISO CERTIFIED
  • PCS - AGENCY TO PROVIDE PERSONAL CARE SERVICES IN THE HOME
  • PRTF - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY
  • RHC - RURAL CLINIC
  • RUH - RURAL HOSPITAL
  • SNF - FACILITY FOR SKILLED NURSING
  • TLF - FACILITY FOR TRANSITIONAL LIVING OF RELEASED OFFENDERS

Deadlines

When Do I Report?

Anyone employed by a medical facility must notify the patient safety officer within 24 hours; the patient safety officer must report the event within 13 days, and must submit a second report with contributing factors, corrective actions, and plan to remedy within 45 days.

Method

How Do I Report?

Nevada State Health Division via RedCAPS

Contact Information

Registrar
500 Damonte Ranch Parkway
Suite 657
Reno, NV 895201
Phone: (775) 684-5297

Administrator
4126 Technology Way
Suite 200
Carson City, NV 89706
Phone: (775) 684-5911

Supervisor
3811 W. Charleston Blvd.
Suite 205
Las Vegas, NV 89102
Phone: (702) 486-3568

Authority

The legal mandate requiring reporting
DISCLAIMER
Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The reporting requirements and legal mandates on this site are not an exhaustive list and Nevada Rural Hospital Partners, Inc. bears no responsibility or liability for any hospitals' or providers' failure to comply with Federal or State laws or regulations.