2009 Annual Hospitals Report - Nevada State Health Division ...

HIGHLIGHTS OF THE REPORT
2009 Annual Hospitals Report
Over the past year NSHD has identified and collected detailed information on just over 500 deficiencies that occurred in
urban and rural hospitals. More than 91% of urban and 53.3% of rural hospitals had complaints filed against them in
2009. However, about two thirds of these complaints were either unsubstantiated or no action was taken or necessary
to remediate the problem. Among all deficiencies life safety code standard was cited most frequently, and appropriate
care for patient was the most widely spread deficiency encountered in 17 urban and 3 rural hospitals. More than a half
of the complaints (57.1%) related to urban hospitals. At rural hospitals, about 40% of complaints were filed by patients
or their families; telephone was the most frequently used method to file these complaints.
About 82.4% (201) of all sentinel events in Nevada during 2009 were reported by hospitals, while less than 18% were
reported by other medical facilities. Similar to observed trends in other states, HAIs accounted for most of the reported
sentinel events, representing about 26%, and falls ranked second with about 17.4%. It is important to emphasize that
more than 46% of all reported sentinel events posed a risk of physical injury to patients and about 28% (56) of those
involved with a sentinel event died as a result.
The Health Division requires that all reporting facilities complete a root cause analysis to determine the exact
circumstances around the sentinel event, a description of what happened and how to prevent recurrences. It would be
very difficult to prevent serious future events without uncovering the root causes of such preventable infections or
injuries. Thorough investigation of sentinel events and detailed analysis for the patterns observed could be very helpful
for healthcare facilities and medical/administrative staff to identify subtle underlying causes, vulnerability in the care
process, miscommunication, or other discrete problems in the hospital policies and procedures. Additionally, such
analyses can be used to identify strategies for improving the overall processes of care, with the ultimate goal of
preventing avoidable harm to patients.
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