Hospitals making mistakes won’t be named

Serious mistakes made by individual hospitals in Spokane and across Washington will no longer be reported to the public following a review of a 2006 law requested by the state hospital association.

Hospital-specific errors such as surgery performed on the wrong body part, items left behind after an operation or the development of life-threatening pressure sores were wrongly disclosed for more than a year, state health department officials said this week.

Information contained in the reports should only have been released in the aggregate and for geographies large enough to prevent identification of the hospitals where the mistakes occurred, said Byron Plan, executive manager of the Office of Health Care Survey.

“We did not pay attention to the changes under the new law,” Plan said this week. “We just continued to do what we did under the old law.”

Last month, Washington State Hospital Association officials asked the health department to stop providing individual hospital reports on 28 serious, preventable mistakes identified by the National Quality Forum, a patient advocacy group. As of Sept. 6, the department agreed, Plan said.

However, a state representative who lobbied to make the reports public said he’s contesting that decision.

“I fought very hard to allow open disclosure,” said Rep. Tom Campbell, R-Roy. “That is not acceptable behavior.”

Campbell said a 2000 law specifically authorized the health department to release the information.

However, a review of the 2006 law revealed that the mistake reports and the information used to create them were confidential under the new statute, said Kristin Peterson, director of legal and clinical policy for the hospital association.

“It’s maybe something we should have looked at earlier, but we hadn’t,” Peterson said.

The new scrutiny was not prompted by pressure from any particular hospital, added Cassie Sauer, a spokeswoman for the hospital association.

Between June 2006 and August 2007, 223 adverse events were reported by the state’s hospitals, the data showed.

The hospital association supports reporting of overall errors to help improve patient safety, but not mistakes logged at individual sites, Peterson said.

“Publicizing reported events at specific facilities has a very punitive effect,” Peterson wrote in a memo to state health officials. “It penalizes reporting without any quality improvement value.”

That’s the same argument made by some hospital officials who objected to public reports of errors.

Dr. Jeff Collins, medical director at Sacred Heart Medical Center, has said that understanding medical errors and steps to prevent them is very complicated and that internal reporting and review is enough to ensure improvement.

Sacred Heart surgeons operated on the wrong body parts twice last spring, according to the adverse event records.

But at Deaconess Medical Center, where eight instances of serious pressure ulcers were reported since the law began in June 2006, one executive said the increased scrutiny improved patient care.

“I would say there’s no doubt that public reporting has helped establish more rigorous quality control,” said Shelley Peterson, chief nursing officer and vice president for Empire Health Services.

However, she added that she didn’t know whether patients used that information to choose health care services.

Information about overall numbers of hospital mistakes will remain available, said Plan, the health department manager. But the data will be sorted by broad geography to avoid identifying individual hospitals.

That’s not good enough, Campbell said. He said he’s consulting with health department officials about the issue. If the hospital association is correct, Campbell said he would introduce a bill next legislative session to make the mistakes public again.

Reporting of hospital errors varies widely across the nation. It’s often voluntary, anonymous or protected. Until Washington reversed its policy, it was among only six states to require mandatory public disclosure. Five states – Minnesota, Connecticut, Indiana, New Jersey and Oregon – require public reporting of adverse events, an official with the National Academy for State Health Policy told the Wisconsin State Journal newspaper this spring.

There’s no denying a move toward transparency, however. By next fall, for instance, all hospitals that receive Medicare reimbursement will have to track whether certain serious, preventable conditions occur after patients are admitted – and forgo funding if they do.

“That’s a big accountability,” Peterson said.