The Utah Department of Health (UDOH), in conjunction with the Utah Hospitals & Health Systems Association (UHA) and HealthInsight, today released the 2009 Sentinel Event Data report for the state of Utah. Sentinel events are defined as unanticipated deaths, wrong-site surgeries, patient abductions, and loss of function that occur at a hospital or ambulatory surgical center and are directly related to any clinical service. The report's release coincides with National Patient Safety Awareness Week, March 7-13.

The report, found online at www.health.utah.gov/psi/Consumer_info.htm, provides information on the sentinel event data collected at all Utah hospitals and ambulatory surgical centers from January-December 2009. During that timeframe, there were 101 sentinel events reported in the state of Utah. Fifty-four of these events were surgical or procedural events. For perspective, more than 152,000 hospital based outpatient surgeries were performed in Utah in 2008. There were more than 262,000 hospital discharges in 2008, with surgeries comprising approximately one-quarter of all discharges. The report also provides a historical overview of the Utah Patient Safety Program as well as information on the collaborative efforts underway to address the issues identified by the data.

"The best way to prevent these events, which can be devastating to patients and their families, is to have a robust, transparent reporting system to monitor and track them," said UDOH Patient Safety Director Iona Thraen. "If we can better track these events we can work together with the health care industry to identify what's causing them and take steps to prevent them in the future."

Over the years, as the sentinel event reporting system has improved, the number of reported events has increased. Factors contributing to the increase reported in 2009 include expanding the reportable event categories, streamlining the reporting process and building trust with reporting hospitals. Population growth, an increase in the number of available beds as well as growth in the number of ambulatory surgical centers operating in Utah may also have played a role in increased reporting.

Although sentinel events are not always medical errors, they are indicators of systemic problems. Identifying events across hospitals and surgical centers allows all players to learn from the past and develop industry-wide fixes..

"Patient safety is of paramount concern to all hospitals and providers in Utah," said Joseph M. Krella, President/CEO of UHA. "We look forward to collaborating with the state, HealthInsight and other providers to find new ways to improve quality of care,"

In 2001, the UDOH developed a volunteer Sentinel Event Users Group (SEUG) and a reporting system with eight general categories. The reporting system was deliberately designed to shift away from a traditional "focus of blame" and instead encourage a culture for collaborative improvement. Between 2001 and 2007, an average of 30-40 annual sentinel events were reported.

The SEUG, now named the Patient Safety Work Group (PSWG), is comprised of representatives from the UHA, the Utah Medical Association, HealthInsight and the UDOH. In an effort to improve reporting, the PSWG has worked diligently to increase the types of events reported and to improve the ease of reporting these events. Consequently, an administrative rule change was implemented mid-2007 to expand the type of events reported from the original eight general categories to 32 specific categories. The motivation for such a change was to be able to compare the Utah experience with national experiences and data.

Additionally, in late 2008, the reporting process changed from a faxed document and manual data entry performed by the UDOH Patient Safety Director to a secure, web-based reporting portal. This portal now supports individual facilities, offers the ability to download facility reports, and enables internal trend analyses.

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