A sentinel event is an action that should “never happen” in a health care setting, including death, serious physical or psychological injury, permanent harm and severe temporary harm. Common examples of sentinel events include falls, pressure ulcers, unintended foreign items unintentionally left, or unanticipated death. The purpose of the Annual Sentinel Events Summary Report is to inform the public on patient safety as reported in the State of Nevada’s Sentinel Events Registry (SER).