Hospitals to patients’ families: No mistakes around here

State numbers show reluctance to admit medical errors

By Peter Korn

The Portland Tribune, Aug 13, 2008, Updated Oct 30, 2009 (5 Reader comments)

An assessment of a state agency charged with getting hospitals to report their mistakes shows that, in some cases, the hospitals might be willing to anonymously report their errors to the agency.

But rarely will hospitals follow state rules that they report the mistakes to the families of their victims.

Fifty-four of Oregon’s 57 hospitals have voluntarily enrolled with the Oregon Patient Safety Commission and agreed to abide by its mandatory reporting rules. One of those rules requires that hospitals notify patients and families in writing after they have been the subjects of what hospitals call serious adverse events — major errors in care.

According to the assessment by the state Public Health Division, released this week, Oregon hospitals in 2007 notified patients or their families only 25 times of serious adverse events — a drop from 2006, according to the report. The report fails to say how many notifications were made to families in 2006, but said that notification took place in 2007 in less than half of the adverse event cases of which state officials are aware.

‘It’s not catching on’

The Oregon Patient Safety Commission was formed by the Legislature in 2003. While a number of other states have similar commissions aimed at reducing medical errors, most of them require hospitals to enroll and participate.

Oregon’s program is unique in that hospital participation is voluntary. Critics have said that only a mandatory reporting system will get hospitals and other care providers to comply, which is why annual assessments of the program are considered crucial to determining whether the commission is getting the cooperation necessary to reduce medical errors.

The commission’s patient notification rule is also unique, according to Patient Safety Commission Executive Director Jim Dameron. Other states have not attempted to require hospitals to disclose their medical errors to victims, which hospital officials believe could open hospitals up to lawsuits.

But Oregon does, and the rule apparently is being flouted.

Dameron himself has estimated that between 800 and 1,700 serious events take place in Oregon health care institutions each year. The state assessment uses data from a Pennsylvania study to estimate that Oregon may have as many as 1,500 serious error events each year. According to the new state assessment, 94 adverse events were reported to the safety commission in 2007.

Dee Dee Vallier, a Hood River patient advocate and former board member of the patient safety commission, said this week that if she were still serving on the board, she would fight to have the commission take over the role of contacting patients and their families.

“I strongly believe it’s a patient’s right to know if they have suffered from an error,” Vallier said. “The risk of not knowing that an error has occurred sometimes prevents the patient from getting the necessary and proper treatment for the injuries suffered. If the hospitals are not doing that, it should be the commission’s responsibility to contact the victims.”

Dameron said he has doubts that hospitals will comply with the rule on reporting to patients and families.

“We’ve always acknowledged that this is difficult,” Dameron said. “It’s not catching on. Hospitals continue to believe that there is a risk involved and we haven’t been able to convince them that there is something essentially good about the idea (of notifying patients).”

Burden of record keeping

But what is catching on, Dameron said, is the confidential reporting from large and middle-sized hospitals after mistakes. The fundamental premise of the patient safety commission is that after hospitals report their errors, the commission can use that information to send out alerts to all hospitals in hopes they can avoid making the same mistakes.

The commission has regularly issued such reports after hearing of hospital mistakes, on issues ranging from syringe bulbs left in patients after surgery to preventing babies from falling from beds.

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