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State presses hospitals for full accounting of preventable injuries
Health Division affirms Sun findings of discrepancy in how hospitals report preventable injuries
Friday, July 16, 2010 | 2 a.m.
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- State presses hospitals for full accounting of preventable injuries
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State officials released data on preventable injuries and infections in Nevada hospitals Thursday that mirror the findings of a Las Vegas Sun investigation.
The newspaper’s analysis of hospital billing records on file with the state has shown a wide discrepancy between the cases of patient harm detailed in those records and the number that hospitals have reported to the state as so-called sentinel events — unexpected incidents that cause injury, or the risk thereof, in a hospital.
The Nevada State Health Division analysis found hospital patients suffered 342 preventable injuries or infections during the second half of 2009, while facilities reported only 44 sentinel events. Each of the 342 cases might fit Nevada’s definition of a sentinel event.
Richard Whitley, administrator of the Health Division, is pressing the hospitals to review medical records from 2009 and see if they failed to report any sentinel events, and to report them now, if need be.
On Wednesday, Whitley sent hospitals a letter accompanied by the state analysis. “We are asking that you reconcile the differences between the (incidents of harm) that were identified at your facility and the sentinel events that your facility reported,” Whitley wrote.
Hospitals are required by law to report sentinel events to the state and affected patients and review the incidents so they are not repeated.
The Sun investigation found that in 2008 and 2009 Nevada patients suffered 1,363 cases of preventable harm in acute-care hospitals. During the same period, the hospitals reported 402 sentinel events.
The Health Division, which licenses hospitals and investigates complaints against them, followed the Sun’s lead in conducting its analysis of hospital billing records, which detail every inpatient visit. The state’s findings were essentially the same as the Sun’s, state officials said.
Hospital officials said they have always abided by the law and have no qualms about the state reviewing medical records, which is the only way to determine whether a sentinel event report should have been filed.
“This is a good opportunity to make the comparisons between the clinical (medical records) and the nonclinical data (billing records) as it may help to clear up some of the questions that have been raised,” said Kathy Silver, CEO of University Medical Center.
In an interview, Whitley said now that the Sun has shown how billing data can be used, the state will incorporate this type of analysis in its regular inspection process. Hospital-acquired conditions will be analyzed quarterly, and the results will be checked against medical records to ensure sentinel events are accurately reported, he said.
Whitley said the state’s actions are not intended to be punitive. Sentinel event reporting is important to patient safety because each incident requires an analysis to determine what circumstances led to the injury. If hospitals are not reporting sentinel events, they may not be doing the analysis needed to protect future patients, he said.
Whitley said he will give the hospitals a “reasonable” period, perhaps 30 days, to report any sentinel events the facilities failed to report during the second half of 2009.
Meanwhile, Health Division surveyors will begin pulling medical records for each hospital-acquired condition identified by the state’s billing record analysis and determine whether the incidents should have been reported as sentinel events, he said. It will take no more than 18 months to complete the statewide review, he said.
Regulators can impose sanctions against hospitals that fail to report sentinel events. The maximum fine is $100 per event, per day the incident goes unreported.
If all the incidents of hospital harm were considered sentinel events, and the maximum fines were assessed, Nevada hospitals could face combined fines totaling $10.8 million.
Each hospital’s willingness to examine its compliance with sentinel event reporting will be taken into account in determining if sanctions are necessary, Whitley said.
Enormous fines are unlikely, he said, adding he does not want a short-term financial gain to get in the way of long-term improvements that would protect patients.
It’s more important to ask “How did this happen, and what are you doing about it?” Whitley said of the apparent underreporting of sentinel events. Hospitals need to examine whether there are breakdowns in their sentinel events reporting process, he said.
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I Don't think the state Health Division would have even addressed this had the Sun not went to work and brought this to the attention of the public, While that other news paper of a rag (RJ) was looking at ways to strong arm others for there enrichment the Sun Has done the work this is why the Sun keeps winning awards!
Thanks Sun
The state should have been all over this years ago. The public deserves the right to choose a hospital with a good track record for safety and the lowest infection rate.
Most likely the state does not have adequate staffing and/or was pressured to keep the data quiet. Remember, hospitals are usually owned by large corporations with big legal and financial clout.
I agree with Libra. This information has been available for years. Why hasn't anyone, like the federal and state regulators, looked at it before and taken action. I think what is most disappointing is that hospitals don't use their own data. I work in a hospital and we generate it. We collect it. It's funny whenever industries have problems the people blamed are the regulators and not the industry who caused the problem. It's probably much like all of the fuss made over these articles. The article becomes the problem not the events in that happen in the hospitals. I also agree that it's all political. The regulators report to the elected officials. They're probably told who to look at under a microscope and who to go easy on. In the hospital we're told what will or won't be reported as an adverse events. We're also not allowed to speak to the inspectors or joint commission when they are investigating. I appreciate The Sun taking the lid off Nevada's health care industry and the secrets. I hope the state regulators continue to push hospitals to be accountable so they don't blame the nurses! Patricia
Hospital administration blames the staff providing the care whenever possible. Whenever the state regulators come into our hospital the goal is to discredit them. We think they're going to report us to the Board of Nursing and the hospital doesn't want any findings that might impact their status with the state or feds. Everything about patient care is political--who gets it, where they get it, how it's paid for, how it's regulated. It's all about making money. I think health care is corrupt at the top!
I appreciate the work of the Las Vegas Sun. Your articles on health care forces hospitals, physicians, government, politicians and even patients to take notice and make improvements in the quality of health care in Las Vegas. Thank you!
I'm amazed Nevada State government moved so quickly from the time this article came out. This has to be some kind of record pace for State government to take an action. Usually the folks in Carson City defend and argue why they do nothing and do it slowly. Refreshing to see government respond timely. Now for the cynicism: Why don't they just start doing it proactively and without needing to be prompted by the press???
Hey GovernmentJustICE (I get it, Government Just Ice): Maybe the folks in Carson City learned something from the Hepatitis C outbreak. Whatever it takes to make government to respond, I'm grateful.
Yeah right!! This is the same state agency that didn't take away Dr. Desai's license until the infected patients started their lawsuits. The Health Department didn't seem to learn how to manage physicians very well. I keep reading about doctors abusing patients and hurting people. Maybe Whitley will write a letter to the sex offender doctors and ask them to please stop. He should take their license away immediately and they should be prosecuted. He didn't seem to learn much from the hepatitis C incident if he lets the doctors doing this keep their license. I'm not grateful. He should just do his job. If doctors are doing harm he should take their license away. I agree with Libra, it's all politics.
How can government regulate itself? UMC is a county hospital, Rawson Neal Psychiatric Hospital is a state operated facility, Desert Willow is an adolescent psychiatric hospital operated by the state, VA hospital is operated by the feds. I bet the State doesn't take action against itself. I'd like to see that story.
I'm on the same page Cop4Life. Government provides the service, government regulates the service, and WE PAY FOR IT. Where do Rory, Brian, Harry and Sharon sit on this one??? Jimmy hasn't done anything about it.