by STEPHANIE GLANTZ & MOLLY MOSER
On Wednesday, the Assembly Committee on Health and Human Services discussed Assembly Bill 28, a bill to revise the definition of sentinel events relating to the health and safety of patients.
State Health Officer and Medical Director for Mental Health and Developmental Services, Dr. Tracey Green, testified on the bill with Nevada State Statistician, Jake Kvam and Health Program Manager to the Office of Public Health Informatics, Julia Peek. The current definition of a sentinel event is any unexpected occurrence involving a hospital or healthcare facility in which a patient dies, acquires an infection, or serious physical or psychological injury. Green says AB28 requests a change in definition because terms used in the bill such as “unexpected occurrence” and “risk thereof” are two issues created by the current definition.
“These terms are ambiguous,” Green says. “They are not statutorily defined, therefore, individual facilities and the state have differences in their uses and interpretations in their reporting.”
The Nevada Revised Statute defines a medical facility as a hospital, obstetric center, surgical center or an independent center for emergency in chapter 439.805. Green said another issue is that there is currently duplicate reporting for facilities to address health care acquired infections to both the Sentinel Event Registry and the National Health Care Safety Network. Green says Nevada also requires medical facilities to do this, but as for reporting it, it’s currently in two places under Nevada statutes: under “sentinel events” and also separately listed in NRS chapter 439.847.
Green said AB28 proposes an aligning of the current definition of sentinel events with the National Quality Forum’s list of serious reportable events, which consists of surgical or invasive procedure events, patient protection events and environmental events. According to Green, this definition by the NQF has been adopted by 14 states for sentinel reporting.
“By adopting the national quality forum definition, AB28 would standardize and define reporting requirements, remove ill defining terminology and eliminate the duplicative reporting of health care associated infections to both the Sentinel Events Registry and HCSN,” Green says.
Kvam said the NQF doesn’t change the definition frequently. NQF recently revised it in 2011by adding more categories to the reporting requirements. Kvam says there will be a notification if the definition happens to change again.
“Fortunately, the language in the proposed bill actually specifies a timeline for the adoption of those,” Green says. “Notifications are received by the health division from NQF when they do make those alterations because we do coordinate with NQF.”
Kvam said updates to the medical facilities that are required to report the sentinel events are sent out and available to the public since Nevada health divisions and NQF would be coordinated together.
“Even if we were delayed by a couple of days, it would be accessible for public posting from NQF, and hospitals could monitor that themselves as well,” Kvam says.
Assemblyman Joseph Hogan made a comment about AB28, saying he wants to focus on expanding the studies of mental health conditions in prisons and mental health problems that develop in elderly people. Hogan says he was impressed with the testimony and would like to see it expand further.
“The ideas are coming out of this discussion I think need to be . . . the way we address the bigger problems with healthcare, instead of having to be almost as deeply embarrassed about the failings of Nevada in mental health and health generally, as we are about the failures in education,” Hogan says.
The hearing for AB28 was closed and the next question that rises to debate with the Assembly is what determines a psychological injury or disorder.