Nevada State Health Division Issues Annual Sentinel Events Report

May 21, 2011

Cover for Nevada May 2011 Sentinel Event Report

The Nevada Department of Health and Human Services, Nevada State Health Division (NHSD) has issued its 2010 Sentinel Event Summary Report.

Nevada’s Sentinel Event Reporting Law

The state of Nevada passed legislation in 2009 that requires the NSHD to issue an annual sentinel event report by June 1st of each year.  This recent report is the second annual report to be compiled under the law.

As compared to other states with stand alone healthcare associated infection (HAI) laws, Nevada is unique in that HAIs are required to be reported under the law along with other types of sentinel events or adverse outcomes.

Under the Nevada Revised Statutes (NRS) section 439.830, a “sentiment event” is defined as:

“an unexpected occurrence involving facility-acquired infection, death or serious physical or psychological injury or the risk thereof, including, without limitation, any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.  The term includes loss of limb or function.”

Medical Facilities Required to Report

Medical facilities are required to report sentinel events directly to the NSHD.  Facilities required to report include:

  • hospitals,
  • obstetric centers,
  • surgical centers for ambulatory patients, and
  • independent centers for emergency medical care.

Sentinel Event Summary Form

In January of 2011, the NSHD sent all subject hospitals a summary form to be completed and returned to NSHD.

The form was sent to 119 mandatory sentinel event reporting facilities.  This included 59 hospitals, 59 ambulatory surgical centers, and one independent center for emergency medical care.

Although obstetric centers are included as reporting facilities under the law, the state does not license these entities, thus, they were not required to report.

Of the facilities reporting, all returned the required forms.  The reports were aggregated to provide the data included in this May 2011 report.

Nevada’s Sentinel Event — Healthcare Associated Infection Rates

For the year 2010, Nevada’s reporting facilities reported data for 415 sentinel events.  Of these reported events, facility acquired infections were the most common, with 167 reported events, accounting for two-fifths (40.2%) of all sentinel events reported.

Surgical site infections were most prominent (41 events); catheter-related urinary tract infections were the second most common (38).

The reported infections included the following:

  • catheter-related urinary tract infection (38 events; 9.2% of all sentinel events reported)
  • central line-related bloodstream infection (24/5.8%)
  • decubitus ulcer (14/3.4%)
  • non-catheter-related urinary tract infection (6/1.4%)
  • non-central line-related bloodstream infection (7/1.7%)
  • surgical site infection (41/9.9%)
  • ventilator associated pneumonia (5/1.2%)
  • facility acquired pneumonia (2 events)
  • Clostridium difficile infection (28 events)

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Reference:  Nevada Department of Health and Human Services, Nevada State Health Division, Bureau of Health Statistics, Planning Epidemiology, and Response, Office of Epidemiology. 2010 Annual Sentinel Event Summary Report (May 2011).


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