States moving ahead on patient safety front

Four states have created safety centers this year.

By Andis Robeznieks — Posted July 26, 2004

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As no action has been taken on patient safety legislation in the U.S. Senate since it reported out of committee Nov. 17, some individual states have decided to act on the Institute of Medicine's 1999 recommendations to develop error-reporting systems and create patient safety centers to collect and disseminate this information.

Twenty-two states now have some type of reporting system in place, and six have created patient safety centers, said Jill Rosenthal, a project manager with the Portland, Maine-based National Academy for State Health Policy.

And while experts concede that there eventually could be some minor duplication of state and federal activities, many believe that the dual systems will evolve into complementary rather than competing roles.

"The states are often the laboratories for health care issues," Rosenthal said. "This is another example where states aren't waiting for the federal government and are moving ahead with their own plans."

Rosenthal said there was still some physician opposition to error-reporting because there is a concern that the information collected will be used against them, but research done by her organization indicates this isn't being done. "We couldn't find any examples of malpractice attorneys using this data," she said.

An NASHP study issued last fall concluded that it was too early to tell what level of error and adverse event reporting improves patient safety, and because four of the state patient safety centers are brand new (Florida, Maryland, Maine and Oregon), Rosenthal said it's far too early to conclude how effective these centers will be.

To help improve the data pool, NASHP invited representatives from the four new centers plus the established ones in New York and Pennsylvania to a July 22 conference in Baltimore to compare notes. Among those invited was William Minogue, MD, who came out of a one-year retirement last month to run the Maryland Patient Safety Center.

"I believe it will be the most exciting thing I've done in my long career," the 74-year-old former internist, educator and hospital administrator said.

Dr. Minogue said a key component of the Maryland program is its "bifurcation" in which errors resulting in deaths and permanent disability will be reported to the Maryland Health Care Commission, while anonymous reports of errors resulting in minor or no harm will be collected and analyzed by the center.

"We're calling it a 'just culture' where, if there are egregious acts, willful acts or criminal acts, call the cops," Dr. Minogue said. "But what we have found, what NASA has found, what the aviation industry has found and what the Veterans Administration has found, is that if you de-identify the individuals and institutions reporting, you get a ten-, twentyfold increase in reporting. It's all about improving the system and processes -- not hanging anybody."

Plans call for first collecting reports on hospitals and nursing homes and then, eventually, systems will be developed for collecting error reports from smaller clinics and private practices.

"There is definitely the intention to do that," said MHCC Deputy Director Enrique Martinez-Vidal.

Embracing technology

Martinez-Vidal said there are four aspects to the Maryland center's mission: data collection, planning collaborative projects among hospitals, education and, eventually, patient-safety research.

A focus will be developing a uniform information technology system, of which Dr. Minogue is a big supporter. "It's an embarrassment the way this profession has not embraced technology," he said.

Implementing technology also will be a focus of the newly created Florida Patient Safety Corp., a three-year pilot project charged with developing "a statewide electronic infrastructure," said Florida Medical Assn. spokeswoman Lisette Mariner.

Developing patient-safety "best practices" will be another of the corporation's tasks, and Mariner said the FMA would be watching to make sure the corporation stays on track in this regard.

"We're going to monitor the situation so the focus remains on patient safety and it is not used as a way to reduce services," she said.

Wyoming is poised to become the 23rd state to develop an error-reporting system, said Wyoming Medical Society Associate Executive Director Susie Wacker.

"I can't foresee how the implementation will happen, but we at the medical society totally support anything that will improve patient care," she said.

Sean Donahue, a senior policy adviser for Sen. Jim Jeffords (I, Vt.) who sponsored the federal legislation, which the AMA supports, said, "Time is running out to get this done." But if the federal bill does pass, he said state efforts would not be in vain.

"I don't think there will duplication and overlap," Donahue said.

Wacker, Mariner and Martinez-Vidal all agreed. "Patient safety is a very hands-on activity, and states are at the front lines and can work with local hospitals and providers," Martinez-Vidal said.

Dr. Minogue, however, stressed the importance of staying committed to patient safety even when tangible results of the effort may be hard to find.

"It's a big marathon we're running," Dr. Minogue said. "But I'm afraid people want it to be a sprint."

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State action

So far, 22 states have answered the Institute of Medicine's 1999 call to create medical error reporting programs. Despite the existence of all of these programs, the National Academy for State Health Policy has concluded that underreporting remains a problem. Here are some of the other findings from the NASHP analysis of state programs:

  • There is no evidence to show what level of data disclosure improves patient safety.
  • More research is needed so that state officials can act on something more than anecdotes, gut feelings or interest group pressure.
  • Uncertainty about requirements, lack of state enforcement, a culture of nonreporting, fear of liability and fear of publicity all lead to underreporting of medical errors.
  • States are hesitant to release data that the public might misunderstand or could unfairly punish compliant reporters.

Source: National Academy for State Health Policy report "How States Report Medical Errors to the Public"

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External links

AMA statement on the Patient Safety and Quality Improvement Act (link)

Thomas, the federal legislative information service, for bill summary, status and full text of the Patient Safety and Quality Improvement Act (S 720) (link)

Maryland Patient Safety Center (link)

Text of Wyoming HB 1001 on medical safety event reporting, in pdf (link)

National Academy for State Health Policy on quality and patient safety (link)

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