Published in: Portland Tribune
Issue/Volume: August 14, 2008
Written by: Peter Korn

8/14/2008 – 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.

Dameron said his commission is helping encourage a culture of patient safety in hospitals around the state. This week’s public health division assessment commends the commission for getting providers to agree to participate – the 54 hospitals, 87 of the state’s 142 nursing homes and 39 of 76 ambulatory surgery centers have signed on. The assessment also notes that the 94 adverse event reports the commission received in 2007 were an increase from 55 in 2006.

But those 94 reports came from 30 of the state’s hospitals, which means that 24 hospitals did not report any adverse events at all for the year.

Dameron said the hospitals that did not report are mostly smaller hospitals, for which the burden of keeping records and reporting to the commission might be greater.

Nursing homes that have signed on with the commission were told to start reporting their adverse events the last three months of 2007. But according to the state assessment, only one nursing home adverse event has been reported.

Dameron said that nursing home administrators have told him that they will start reporting their mistakes once the commission’s electronic reporting system is up and running. The system will allow administrators to report events online directly to the commission and is expected to be operating by the end of September, Dameron said.

Few pharmacies participate
The public health division’s report glosses over what may be the patient safety commission’s greatest obstacle – it has been unable to get the state’s pharmacies to participate.

A story in the Tribune last year revealed that the state board of pharmacy investigated 300 complaints of adverse drug events last year, but that no Oregon pharmacists voluntarily reported any events to the board of pharmacy.

When the legislature created the patient safety commission, it directed the commission to enroll pharmacies in addition to hospitals, nursing homes, and ambulatory care centers. As with hospitals, the reports from pharmacies would be be kept confidential by the commission. The commission would even keep the reports confidential from the state board of pharmacy.

But even that promise doesn’t seem enough to get the state’s approximately 700 pharmacies to participate in reporting their mistakes.

After more than a year of recruiting, only 75 pharmacies have enrolled with the patient safety commission. And 50 of those are Fred Meyer pharmacies. Fred Meyer was the only pharmacy chain willing to participate.

That has Dameron concerned.

“We have continued resistance from the rest of the chains,” Dameron said. “And that’s a big deal.”

Dameron said he is going to make one more push to get pharmacies to enroll. And if that fails, he said, the legislature may have to consider making participation with the patient safety commission mandatory for pharmacies.

Ex-board member Vallier said she would like to see the Legislature make all participation with the commission mandatory.

“Even though it’s successful, it’s not as successful as it could be,” Vallier said.

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