Hospitals' mistakes are going unreported

[NRSKarenRN, BSN, RN]

Hospitals' mistakes are going unreported

Phila. Inquirer

Posted on Fri, Sep. 12, 2008

...For several years now, hospitals in Pennsylvania and New Jersey have been required to report medical mistakes and serious complications to state agencies charged with reducing medical errors. But some hospitals aren't fully complying, undermining efforts to improve patient safety, experts say.

In New Jersey, five of the state's 80 hospitals failed to report a single preventable mistake last year, officials said. In Pennsylvania, some facilities didn't report any serious events or even the near misses that might have harmed patients.

"I don't know how many is enough, but zero is a bad number," said James Bagian, head of the Department of Veterans Affairs' National Center for Patient Safety.

"Anybody that is supposed to report close calls and has zero reports is clueless," he said. "Management is asleep at the switch and just waiting until they kill someone."...

[SuesquatchRN, BSN, RN]

The average is 40 events per 100 charts?

Oy.

[oramar]

I wonder if these are facilities that still deal with mistakes by punishing the person who reports the mistakes. The culture that deals with mistakes in a punitive manner tends to be very hard to eradicate. We still have people coming here and posting threads that ask, "who should be punished in this particular case?". You can't get administrations to just step up and begin reporting this stuff. They need to introduce a whole new culture which includes their own attitudes. Sometimes it is tough for old dogs to learn new tricks.

[lpnflorida, LPN]

Can hardlly wait until those states which will make those mistakes public. The public has so much information now, and without someone next to them interpreting near misses and how they become learning tools to change.. oh gosh,,,,,,,,,,,,,,,

I agree errors and near misses need to have incident reports and followup, but to be public. I am not sure of all the possible reprecussions of that.

[RN Power Ohio]

The biggest possible "reprecussion" of reporting is that the public will demand improvements in the manner in which care is delivered. In addition, hospitals that are running around the world professing they provide world class care will have to rely on more than a huge advertising budget to make such claims.

Preventable adverse events are just that- preventable.

One hospital study hospital was able to reduce surgical site infection from 30% to 0!!! By implementing some simple processes.

Other countries have nearly eliminated MRSA through vigilant "search and destroy" methods rather than the "monitoring' we have in place here.

Public disclosure is necessary in a virtually unregulated and unchecked industry - like healthcare in the US. Don't be fooled by JCAHO, Magnet and other phony regulations. In most states the department of health has virtually no oversight of hospitals. One thing has become clear- we really have no idea how many people are dying because of unsafe conditions, poor policy, lack of spreading vital knowledge that is gained through research- but it is way too many.