Oregon took patient safety so seriously it created the Oregon Patient Safety Commission in 2003. Almost 10 years later, if Oregon is truly serious about reducing medical errors, there have been clear signs that what we have is not working.
Oregon’s program requires a few simple components if it’s going to work:
• Medical mistakes must be reported.
• The mistakes must be analyzed to figure out what went wrong.
• Recommendations must be made to avoid mistakes in the future.
So if the mistakes don’t get reported, the commission’s work is sabotaged. And again and again when the commission issues reports, it says it is having trouble getting entities to voluntarily report medical mistakes.
This month the commission issued its 2011 report of “adverse events” for ambulatory surgery centers. Events are things such as medication errors, infections and something left behind by mistake in a patient.
There’s been a decrease. There were 124 reported events in 2011. In 2010, there were 245.
But the marked decrease in 2011 is not a reason to believe the commission has been successful. The commission says: “The decrease is not an indication that fewer adverse events are occurring, but rather, that fewer adverse events are being reported. While over 56 percent of the ASCs in Oregon participate in the Patient Safety Reporting Program, only 47 percent are currently reporting adverse events.”
The problem, then, is twofold. Not every surgery center is participating and not all of the surgery centers that are participating are reporting when mistakes are made.
It’s important to note that Oregon’s patient safety reporting system is confidential. There are legal protections in place for this program that keep secret the identity of the people making a mistake and the confidentiality of patients.
Oregon’s system is also voluntary. Surgery centers, pharmacies, hospitals and so on can decide if they want to participate in the state’s patient safety program. There are no penalties.
When the commission was created, it chose a go-slow approach. It was a new commission. It was putting new requirements on the medical community in a sensitive area. Jim Dameron, the former executive director of the commission, used to say patient safety should not be about blame and shame but building trust in the medical community.
But if almost 10 years later, medical providers aren’t participating or aren’t reporting, isn’t it time Oregon gets serious about medical errors for patients?