Hospitals Fail To Report Over 900 "Sentinel Events"
A newspaper's investigation into two years of data from Las Vegas-area hospitals shows patients suffered more preventable injuries, life-threatening infections or other harm more frequently than was initially reported. The data published in a copyrighted story by the Las Vegas Sun was drawn from records of 425,0000 inpatient visits in a state database.
State law requires “sentinel events” – unexpected events that cause serious injury or the risk thereof – be reported to a statewide registry. According to the newspaper, hospitals may not be reporting all incidents. The Sun identified 1,363 sentinel events between 2008 and 2009. Hospitals reported just 402.
None of the hospitals disputed the findings, but argued that many of the incidents don't meet the definition of a sentinel event. Patricia Scott, vice president of quality for Iasis Healthcare Corp., owner of North Vista Hospital, said each medical record is examined before it’s decided whether an incident is reported as a sentinel event. Scott said hospitals consider the course of an illness and a patient's condition before determining whether an adverse event was unexpected, she said.
Nevada can fine hospitals for inaccurate reporting of sentinel events. Based on the newspaper's findings, Richard Whitley, administrator of the Nevada State Health Division, which licenses hospitals and investigates complaints, said he plans to ask hospitals to report any previously undisclosed sentinel events. State investigators will also pull medical records to determine the accuracy of each facility's sentinel events reporting, he said.
In 2007, Nevada lawmakers passed legislation requiring facilities to report incidents of patient harm. The information is to be posted on a website for use by consumers, although some say data collection has been hampered by budget cuts and inaccurate reporting. Hospital lobbyists have fought transparency and successfully argued to keep the public portion of the data limited to statewide totals.
“The hospitals have been resistant to change every step of the way,” said Assembly Speaker Barbara Buckley, D-Las Vegas, a proponent of the sentinel-events legislation. Buckley said the intent of the registry data was to increase hospital transparency, reduce costs associated with errors and improve the quality of care.