Nevada hospital administrators that, for years, have been under- or misreporting sentinel event data at their facilities are in for a rude awakening as a result of an extensive review of preventable injuries conducted by the Las Vegas Sun. The newspaper, which determined that patients suffered from preventable incidents of harm at such hospitals a whopping 969 times from 2008 to 2009, also reports that investigators in Nevada are now set to request previously unreported sentinel event information with the intention of fining hospitals for prior inaccurate reporting.
"Since the Las Vegas Sun identified this analysis of data, we are certainly going to make use of it as well," Richard Whitley, the administrator of the Nevada State Health Division, told the newspaper. "It's all about improving the quality of healthcare."
Some of the sentinel events made public by the newspaper included:
- A Sunrise Hospital & Medical Center patient who died after her windpipe was torn out during the insertion of a breathing tube, causing oxygen to be pumped into her chest cavity instead of her lungs.
- A St. Rose Dominican Hospital patient whose healthy kidney was removed after a surgeon mistook the organ for a cancerous tumor during a colostomy bag removal operation.
The Sun also found significant differences in data that was reported to the state and information recovered during the newspaper investigation. For example, while only one sentinel event involving central-line bloodstream infections was reported to the state in 2009, 336 such incidences were discovered by the newspaper. Hospitals in 2009 also only reported six instances of accidentally leaving a foreign object in a patient's body after an operation; the Sun discovered 17 such occurrences.
Even more disturbing, many of the hospitals tried to argue that the statistics uncovered weren't "sentinel," but instead were "adverse"--a term with no legal repercussions in Nevada, according to the newspaper. However, Assemblywoman Sheila Leslie (D-Reno), who helped write the state's sentinel events definition in 2002, told the Sun that its findings could indeed be categorized as such.
Dr. John Santa, director of the Health Ratings Center for Consumer Reports, called the investigation important in terms of figuring out how the hospitals prioritized patient safety. "These are events that no one can be proud of," he told the newspaper. "They aren't inevitable. They're preventable. It just involves attention to detail and a willingness to change culture."
For more information:
- read the Las Vegas Sun article
- sort through the rest of the Sun's findings