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Medical errors: So much time, so little progress

Post by Kim Bradford on Aug. 11, 2009 at 8:49 pm with No Comments »
August 11, 2009 8:49 pm

This editorial will appear in Wednesday’s print edition.



Americans up in arms over the future of U.S. health care should spare some outrage for its present.


A Hearst Newspapers investigation has found that a decade after the National Institute of Medicine urged the health care industry to stop blaming doctors and nurses and find ways to prevent medical errors, little has happened.


A mandatory nationwide system for reporting and analyzing medical mistakes never got built, and its prospects grow dimmer by the year. Meanwhile, some experts say the rate of medical error is increasing.



Even states such as Washington that seem to be at the forefront of patient-safety efforts have spotty records of enforcing their rules.


State Rep. Tom Campbell, R-Roy, has made a seven-year campaign of pushing medical-error reporting. He won legislation in 2006 to require hospitals, birthing centers, prison medical facilities and inpatient psychiatric centers to report 28 "adverse health events."


Today, a third of the state’s hospitals haven’t filed a report, and none of its birthing centers, prison facilities or psychiatric hospitals have. Statistics suggest that even hospitals that are cooperating aren’t reporting everything they should.


Campbell accuses hospitals of stalling because they fear that "patients will vote with their feet" if the public finds out which ones are error-prone – which is exactly the point of public disclosure of medical errors. Few things are as effective at getting institutions to clean up their acts as the light of day.


But the state, too, has been remiss. Washington law says reporting is mandatory, but licensing officials don’t take action against nonreporting institutions. The Legislature didn’t help matters by – even in good budget years – shorting the Health Department the money it needed to hire a contractor to analyze error reports and build an online reporting tool.


But this state’s leaders still remain the best bet for shoring up patient safety since the prospects for action on the federal level are looking exceedingly dim.


The Obama administration does not support a nationwide, mandatory reporting system and isn’t taking any steps to undo federal regulations that direct reports about dangerous events in hospitals to privately run patient safety organizations that operate with little oversight.


Washington lawmakers, fresh from staring down a $9 billion budget shortfall, would be hard-pressed to find the money they should have coughed up in better times.


But it shouldn’t cost them a thing to suggest the state Department of Health could help underscore the "mandatory" in mandatory reporting law by initiating an investigation or two of facilities that decline to comply.

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