Sentinel events signal the need for immediate investigation and response, and sentinel event reporting can be a useful continuous quality and patient safety improvement tool. Per NRS 439.830, a sentinel event is defined as “an unexpected occurrence involving facility-acquired infection, death or serious physical or psychological injury or the risk thereof.” The event is considered unexpected if it is not related to the natural course of the patient’s illness or underlying condition. The lower the number the better.
Hospitals with less than 100 licensed beds are considered low volume. Low volume
refers to the occasion when there is a small number of cases or a
smaller denominator. Low volume could impact patient confidentiality
and also limit the ability to reliably identify quality differences.
Low volume is a frequent problem in performance measurement, especially
when using measures based on rare occurrences such as Sentinel Events.
For example, a single hospital may only have one death in a year. It
would be difficult to ensure protection of patient confidentially in
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