Oregon Starts Program to Track Medical Mistakes

Oregon has started its program to track medical errors at hospitals and determine what could have been done to prevent them.

The Oregon Patient Safety Commission unanimously approved rules and guidelines for its effort to get hospitals to report serious mistakes.

The Legislature created the commission in 2003, asking it to help reduce the risk of serious errors in the state’s health care system. Gov. Ted Kulongoski appointed the commission members, who include consumers, doctors as well as representatives of hospitals, nursing homes and pharmacies.

In 1999, the Institute of Medicine estimated that between 44,000 and 98,000 patients die in U.S. hospitals each year as a result of medical errors.

The report concluded that most serious mistakes result from communication breakdowns amid the growing complexity of today’s health care system. The root cause, however, is often something not that complex, such as on-the-job stress, sleep deprivation or the overuse of abbreviations in medical paperwork.

The commission will not require hospitals to participate in the program, but those who refuse to take part will be reported on the commission’s Web site.

The commission will rely on voluntary reporting because its members think doctors, nurses and hospitals are more likely to disclose errors if they can do so without fear of penalty. They say it’s more important to learn from and prevent errors than to affix blame.

Jim Dameron, the commission’s administrator, said he hopes half of the state’s 59 hospitals will be reporting by June, and most or all of them by the end of the year.

Information that Oregon hospitals report to the commission is confidential, subject to neither legal discovery in a lawsuit nor the state public records law.

By law, such notification cannot be used as an admission of liability in court, but it does not prevent a patient from filing a malpractice suit.

The commission will not create hospital scorecards, but it will post statewide data and list participating hospitals on its Web site.

Oregon’s new reporting rules eventually will apply not only to hospitals, but also to nursing homes, pharmacies and outpatient surgery centers.