Sentinel Event Information

Sentinel events signal the need for immediate investigation and response, and sentinel event reporting can be a useful continuous quality and patient safety improvement tool. Per NRS 439.830, a “sentinel event” is defined as an unexpected occurrence involving facility-acquired infection, death or serious physical or psychological injury or the risk thereof. The event is “unexpected” as it is not related to the natural course of the patient’s illness or underlying condition.

The tables below show sentinel event information for Nevada Hospitals in 2005, 2006, 2007 and 2008.

 

  TABLE I: NUMBER OF SENTINEL EVENTS - HOSPITALS ONLY
 
Type of Facility (Hospitals)
2005
2006
2007
(As of
6/30/08)
2008
Total
  Acute Care Hospitals
108
160
84
48
400
  Inpatient Psychiatric Hospital
6
5
1
1
13
  Inpatient Rehabilitation Hospital
9
14
6
2
31
 
TOTAL
123
179
91
51
444
 
  TABLE II: NUMBER OF EVENT TYPES BY YEAR - HOSPITALS ONLY
 
Sentinel Event Type
2005
2006
2007
(As of
6/30/08)
2008
Total
  Abduction - Infant - Attempted
1
0
0
0
1
  Assault
0
0
1
1
2
  Battery
1
0
1
0
2
  Burn
1
1
2
1
5
  Contaminated Product/Device
0
0
0
2
2
  Discharge to Wrong Family/Caregiver
0
0
0
0
0
  Electric Shock (Environmental)
0
0
0
0
0
  Elopement
1
5
0
0
6
  Elopement - Attempted
0
1
0
0
1
  Fall
8
12
11
3
34
  Homicide
0
0
0
0
0
  Impersonation of a Health Care Professional
0
0
0
0
0
  Infant Perinatal
4
2
3
1
10
  Maternal Intrapartum
1
1
0
0
2
  Medication Error(s)
8
19
6
2
35
  Nosocomial Infection (pre October 2005)
4
0
0
0
4
  Nosocomial Infection-Central line-related bloodstream infection
3
2
2
0
7
  Nosocomial Infection-Non-central line-related bloodstream infection
7
9
0
0
16
  Nosocomial Infection-Surgical site infection
8
10
8
4
30
  Nosocomial Infection-Catheter-related urinary tract infection
11
6
4
3
24
  Nosocomial Infection-Non-catheter-related urinary tract infection
8
47
8
4
67
  Nosocomial Infection-Ventilator-associated pneumonia
5
3
0
0
8
  Nosocomial Infection-Decubitus Ulcer (Stage 3 or 4)
0
0
0
0
0
  Nosocomial Infection-Other-Eye
1
2
0
0
3
  Nosocomial Infection-Other-Gastrointestinal
1
1
0
1
3
  Nosocomial Infection-Other-Skin
2
7
2
4
15
  Nosocomial Infection-Other-Lower Respiratory
2
6
1
1
10
  Nosocomial Infection-Other-Upper Respiratory
0
4
0
1
5
  Procedure Complication(s)
8
12
12
2
34
  Rape - Attempted
1
0
0
0
1
  Restraint
1
0
0
0
1
  Suicide
1
1
0
1
3
  Suicide - Attempted
2
2
2
6
12
  Transfusion
0
2
1
2
5
  Treatment Delay
14
5
12
3
34
  Treatment Error
6
6
5
6
23
  Wrong Patient/Wrong Surgery Procedure
1
1
1
0
3
  Wrong Site/Surgery Procedure
4
3
3
0
10
  Other
8
9
6
3
26
 
TOTAL
123
179
91
51
444
 
  TABLE III: SENTINEL EVENT OUTCOMES BY YEAR - HOSPITALS ONLY
 
Type of Outcome
2005
2006
2007
(As of
6/30/08)
2008
Total
  Death
38
23
16
9
86
  Physical Injury with Permanent Loss
6
10
7
0
23
  Psychological Injury with Permanent Loss
0
0
1
0
1
  Physical & Psychological Injuries with Permanent Loss
0
1
0
3
4
  Nosocomial Infection with no adverse outcome or risk of adverse outcome
43
96
23
16
178
  Risk of Death
14
15
7
5
41
  Risk of Physical Injury with Permanent Loss
18
33
35
15
101
  Risk of Psychological Injury with Permanent Loss
4
1
2
3
10
 
TOTAL
123
179
91
51
444

 

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