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DHS news release

Jan. 30, 2004

Contact: Bonnie Widerburg (503) 731-4180
Technical contact: Grant Higginson, M.D. (503) 731-4000

Conference will focus on implementing Oregon’s new patient safety law

State and national experts will convene in Portland next week to discuss patient safety and how to launch Oregon’s new patient safety law.

The conference, "Oregon Patient Safety Commission: Moving from Theory to Practice" is set for Feb. 4 and 5 at the Lloyd Center Doubletree. Representatives from a broad spectrum of the health care industry, Legislature, governor’s office, state agencies and consumers will attend. Participation is by invitation.

"This conference will educate and mobilize those who have a stake in improving patient safety," said Grant Higginson, M.D., state health officer in the Oregon Department of Human Services (DHS). "It’s also their opportunity to give input in how best to reduce medical errors through Oregon’s new patient safety reporting system."

The system, created by the 2003 Legislature, has four major components:

• Creates the Oregon Patient Safety Commission as a semi-independent state agency charged with improving patient safety by reducing medical errors. It will have a 17-member board of directors.

• Charges the Patient Safety Commission with establishing a confidential, voluntary, reporting system for serious adverse events.

• Ensures an analysis of the adverse event is conducted and a corrective action plan is instituted.

• Allows participating organizations to share information about errors. Currently such sharing does not take place. Within the Commission, information will be gathered, tabulated and distributed so that participants will learn from each others’ mistakes and successes.

Higginson said that at least 25 other states have reporting systems for medical errors. Oregon's is unique in at least three ways:

• It creates an independent commission to collect and to use patient safety data.

• It combines voluntary reporting with mandatory financing by participants.

• It gives the state public health officer a special independent role to certify the work of the commission and to assure it is held accountable.

The first day of the conference is focused on key health care organizations, purchasers and patient safety stakeholders. Feb. 5 is a half-day working session for the newly appointed Board of Directors and discussion will center on how best to implement the law, maintain public accountability, and measure effectiveness of the commission’s work.

The conference is co-sponsored by DHS and the federal Department of Health and Human Services Agency for Healthcare Research and Quality, along with Kaiser Permanente, Oregon Association of Hospitals and Health Systems, Oregon Coalition of Health Care Purchasers, Oregon Health and Science University, Oregon Healthcare Association, Oregon Medical Association, Oregon Nurses Association, Oregon State Pharmacists Association and Regence BlueCross BlueShield of Oregon.

Higginson said that a 1999 Institute of Medicine report estimated that 44,000 to 98,000 Americans die each year in hospitals as a result of medical errors. Several studies have shown that 50 to 60 percent of these errors are preventable, and are a result of systems breakdown.

Medical errors aren't limited to hospitals, although the problem has not been well studied in other health care settings. The federal Veterans Administration system believes that as many as 180,000 deaths occur each year from "errors in medical care" across all settings, according to Higginson.