NAC439.917. Mandatory investigation of sentinel event by medical facility; plan to remedy causes or contributing factors; confidentiality.

     1. Within 45 days after reporting a sentinel event pursuant to NRS 439.835, the medical facility shall conduct an investigation of the causes or contributing factors, or both, of the sentinel event.

     2. The investigation conducted pursuant to this section must:

     (a) Determine whether changes in the policies, procedures or processes of the medical facility are necessary to prevent a subsequent sentinel event under similar circumstances.

     (b) Follow a nationally recognized methodology for conducting an analysis of the root cause of the sentinel event, including, without limitation, the methodology prescribed by:

          (1) The Joint Commission; or

          (2) The United States Department of Veterans Affairs National Center for Patient Safety.

     (c) Be provided to the Division upon request.

     3. Except as otherwise provided in subsection 4, a medical facility shall, after conducting an investigation pursuant to this section, develop and implement a plan to remedy the causes or contributing factors, or both, of the sentinel event. The plan must:

     (a) State how each finding of the investigation will be addressed and, if necessary, corrected by the medical facility;

     (b) Identify the changes and corrective actions that will be implemented by the medical facility to reduce risk to patients or provide an explanation for not implementing any changes or corrective actions;

     (c) Provide the title of the person responsible for implementing each change and corrective action identified in the plan;

     (d) Provide a timeline for implementing the plan, including, without limitation, when each change or corrective action will be implemented by the medical facility;

     (e) Provide for an evaluation of the effectiveness of the plan and a method for making revisions to the plan based on the evaluation;

     (f) Establish a schedule for monitoring and assessing the continued effectiveness of the plan; and

     (g) Provide the title of the person who is responsible for monitoring the overall plan.

     4. If, after conducting an investigation pursuant to this section, a medical facility determines that a plan to remedy the causes or contributing factors, or both, of the sentinel event is not necessary, the medical facility shall prepare a written statement documenting the reasons for making such a determination.

     5. Except as otherwise provided in this section and NRS 239.0115, information provided to the Division relating to the plan developed pursuant to subsection 3 or the statement prepared pursuant to subsection 4 and any additional information requested by the Division is confidential, not subject to subpoena or discovery and not subject to inspection by the general public.

     (Added to NAC by Bd. of Health by R044-10, eff. 10-15-2010)