Summary

Watchdog groups such as the Health Research Group of Public Citizen are calling for policy reform to protect the safety of patients. Regulators say they want to improve patient safety by adopting a cooperative, rather than punitive, relationships with hospitals.

Original source:
http://seattlepi.nwsource.com/local/222943_safety05.html

Details

• When a Washington hospital amputates the wrong leg, makes a fatal medication error or discovers any such mistake has seriously hurt a patient, state law demands that the facility notify regulators within two days.
• It may surprise patients to hear that a major health care mistake does not immediately trigger an independent investigation -- or even a phone call from the state.
• In fact, most states don't even require hospitals to report such errors.
• And although slim resources delay follow-up by Washington regulators on such incidents, the system is passive by design.
• In general, hospitals are expected to be their own primary investigators.
• That has some patient advocates calling for fundamental changes, here and nationwide.
• About half of them involved deaths or disability, said Byron Plan, executive manager of the state health department's Office of Health Care Survey.
• But the state does not investigate such reports until the hospital is due for its next routine licensing inspection -- unless someone files a complaint or the news media reports an incident.
• For example, an investigation was ordered last month after the Seattle Post-Intelligencer published articles about a Virginia Mason Medical Center patient who was accidentally set on fire during a surgical procedure in 2003.
• In that case, no violations of hospital licensing rules were found, the health department said earlier this week.
• In general, regulators chose a wait-and-see approach because they wanted to evaluate the event within the context of the hospital's own internal review, Plan said.
• Certain mistakes demand assertive independent oversight to prevent systemic problems in hospitals, such as poor medication management, from leading to repeated errors, Wolfe said.
• The state would like to require hospitals to report "adverse events" within 45 days of the incident, rather than giving them unlimited time to confirm such events.

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