Oregon patient safety commission releases new report on state hospitals

Oregon patient safety commission releases new report on state hospitals

par Astrid Fiano, DOTmed News Writer | August 26, 2010
Adverse event
reporting encouraged
The Oregon Patient Safety Commission, a semi-independent state agency that studies and makes recommendations to the state's health care system, has released a new report on hospital adverse events, medical errors, patient safety efforts, and overall progress during the last two years.

According to the report, hospitals in the state are improving compared to 2008 benchmarks, but are only average compared to hospitals in other states. Between 2006 and 2009, hospitals had reported 383 adverse events to the commission. The most frequent events reported were falls, objects left in patients during surgery, and medication errors. From those events, hospitals reported 32 preventable deaths in 2009, and a total of 102 deaths since 2006.

The Commission found hospital leadership "very involved" in addressing adverse events and medical errors, but were less successful in informing hospital boards of serious adverse events, particularly in medium and small hospitals.

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Although hospitals in the Commission's reporting program sign an agreement to provide written notification to patients or patient representatives after a serious adverse event, the commission notes that in 2009 only a little over half of the events were reported to patients. "Clearly this remains a difficult issue for many hospitals," the report says, "though some have reported success in implementing a meaningful written notification policy."

The report also states that 81 percent of Oregon hospitals use a safe surgery checklist to reduce surgical errors, but there are many different versions of the standardized checklists. "Evidence suggests that too much variation can reduce a checklist's effectiveness," the report concludes.

The next steps the commission says it plans to take include:

--Setting clear expectations about the overall volume of reporting it expects to see from hospitals;

--Working with hospitals on the definition of a reportable adverse event;

--Developing a consensus-based guidance on investigation needed for different types of adverse events;

--Providing hospital-specific analyses to participants at more frequent intervals;

--Working with small and medium sized hospitals to improve their board involvement in adverse event review;

--Improve compliance with written notification requirements by providing hospitals with successful case studies and additional information about model notification letters;

--Continue to champion the use of the safe surgery checklist; and

--Explore the concept of 'safe harbor' legislation as a means of increasing the use of best practices.

The full report may be accessed here.