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Hospital Error Reports Up Slightly in Oregon -- And That's Good News.

Reports of errors in Oregon hospitals grew slightly last year, according to the Oregon Patient Safety Commission.

But that might actually be good news.

The commission relies on voluntary reporting, and has been struggling to persuade hospitals to improve their reporting. More reports will allow the state to better improve safety, says Bethany Higgins, the commission's executive director.

"You can clearly see that there's improvement across the board with the quantity as well as the quality of the reports submitted, as well as the timeliness with which they are submitting them," she said, adding, "We have a long ways to go."

Lawmakers created the commission in 2003 as a collaboration between state officials and the health care industry, including hospitals. Its goal: improve patient safety by reporting on "adverse events" -- more plainly, errors in health care.

The number of hospital errors reported in 2011 represents a slight improvement over prior years, but is still a tiny fraction of the number thought to be occurring and go unreported, based on research.

Of the 142 incidents reported in 2011, 88 involved serious harm to patients. Surgical teams accidentally left foreign objects, including 15 sponges, inside 27 patients. Six times hospitals reported surgery performed in the wrong part of a patient, and 11 times reported serious patient harm due to medication errors. At least 22 patients died due to errors, according to the report. The results aren't broken down by hospital.

However, the state knows it isn't hearing about everything. Even if the commission hits its goal of 500 incidents reported annually, it would represent only 0.4 percent of all the estimated hospital errors thought to be occurring in Oregon, the report said.

For instance, hospitals reported only nine health-care associated infections to the safety commission; however, hospitals report a far larger number of infections to the Oregon Office of Health Policy and Research; a recent report found 37 infections related to catheters placed into a large vein alone, and dozens of other infections. Unlike safety commission reporting, infection reports are required by law.

Naomi Kaufman Price is a consumer member of the safety commission. Speaking for herself and not the commission, she noted that studies have shown that better quality procedures can virtually wipe out "wrong-site" surgeries as well as the problem of leaving foreign objects inside patients.

She added that the relatively small number of reports submitted is also a concern.

"We really need in Oregon a way to increase reporting adherence so that we can improve our knowledge and prevent these things from happening," she said. "It's the only way we're going to learn."

According to Higgins, there are 26 other states with similar commissions; Oregon's is the only one that uses voluntary reporting. However, others lack teeth in enforcing the reporting requirement, she said.

Source: The Oregonian http://www.oregonlive.com/health/index.ssf/2012/08/hospital_error_reports_up_slig.html

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