Tuesday, Aug. 10, 2010 | 2:01 a.m.
Nevada lawmakers eight years ago approved legislation that required hospitals to report “sentinel” events to the Nevada State Health Division, for the purpose of identifying unexpected occurrences so that the medical facilities could prevent their recurrence. By improving health care, hospitals could persuade more Southern Nevadans to visit the valley’s medical facilities for treatment rather than seek alternatives out of state.
It is obvious, though, that the law has not been followed. As reported Monday by the Sun’s Marshall Allen in his ongoing investigation into lethal bacteria in Las Vegas hospitals, state billing records indicated 1,052 cases last year of patients who contracted either of two deadly, drug-resistant forms of bacteria known as MRSA or C. diff while hospitalized. Yet hospitals statewide reported only 75 infecti ons as sentinel events in 2009.
Assembly Speaker Barbara Buckley, D-Las Vegas, was on the mark when she described as “staggering” the gap between what the hospitals reported and what was reflected in billing records. Buckley said: “There tends to be underreporting when there’s bad news to report. It’s human nature. But you can’t change practices if you don’t learn of the problem in the first place.”
This is precisely why the Nevada Legislature next year should strengthen the law so it clarifies what hospitals are required to report.
Assemblywoman Sheila Leslie, D-Reno, told the Sun she intends to do just that. The Legislative Committee on Health Care is considering similar legislation.
A good place to start would be to verify that all cases where patients contract a bacterial infection while hospitalized are reported to the state. Those cases certainly fit the definition of unexpected occurrences that should be considered sentinel events. But merely requiring that events be reported is not enough to reduce the number of hospital-caused infections.
The data should also be analyzed to make sure that medical facilities are taking the right steps to prevent the spread of infections and other sentinel events. That is why lawmakers should make sure that the health division has the staffing and expertise necessary to analyze sentinel events, as it has pledged to do, and make sure hospitals take corrective action.
In 2009 legislators added teeth in the form of penalties for hospitals that fail to fully report sentinel events. The fine is up to $100 for each day a sentinel event was not reported by a hospital. It is possible the combined fines could total millions of dollars. It seems time for these teeth to bite. Maybe only then will health care professionals stop forgetting to wash their hands, exposing uninfected patients to infected ones and failing to fully clean rooms between patient visits.
Patients who put their trust in Las Vegas hospitals deserve at least that much, which is why this legislation merits high priority in 2011. We cannot afford the status quo of having patients needlessly exposed to MRSA or C. diff, infections that could be preventable if hospitals did their job better.