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DHS news release

July 10, 2007

General contact: Bonnie Widerburg, 971-673-1282
Program contact: Joel Young, 971-673-1269

Patient safety reporting system receives first assessment

An independent assessment released today shows that after its first year of operation, the overall integrity of the Oregon Patient Safety Commission Hospital Reporting Program is good.

The 2003 legislature created the Oregon Patient Safety Commission to prevent harm to patients and encourage a culture of patient safety. It also charged the Commission with creating a confidential, voluntary system by which health care facilities could report serious adverse events, including medical errors.

Research shows that most adverse events result from system failures, rather than from one person's actions. The reporting program is built on the principle of sharing and learning from adverse events, so health care organizations can establish quality improvement and best practice standards that will improve patient outcomes.

The assessment comes in the form of a certification report by Susan Allan, M.D., J.D., M.P.H, state public health director in the Oregon Department of Human Services Public Health Division.

"The Commission has taken important steps toward developing a strong reporting system, which is a key tool for improving patient safety," Allan said. "Its future success will depend on the increased participation of healthcare providers, but this is a good start."

Hospitals are the first group to begin reporting to the program. Eventually, five other types of health care facilities will also participate: retail pharmacies, nursing homes, ambulatory surgery centers, outpatient renal dialysis facilities and freestanding birthing centers.

Some of the key certification findings are:

  • The Commission achieved excellent hospital enrollment rates for the first year of a voluntary program: 52 of 57 hospitals.
  • During its first year, the program received 55 adverse event reports from 28 of the 52 enrolled hospitals.
  • The quality of most reports is high. Most contain a clear description of what happened, a thorough analysis of why the adverse event occurred and a credible plan of action to address the system breakdown.
  • Both the number of reports submitted and the proportion of participating hospitals submitting reports are too low. Allan noted the reporting level to Oregon's voluntary system is within the range of other states, which have mandatory systems.
  • Hospitals made progress in reporting serious adverse events in a timely and consistent manner to patients and families. Letters to individuals and families had been provided for 68 percent of the reported events and some were still pending.

A number of other states have reporting systems, but Oregon is the only one that has a formal certification process. The certification is intended as an accountability tool and a way to show the public if the reporting program is doing what it set out to do, Allan said.

"The certification is a novel assessment, phased approach that has not been used elsewhere," Allan said. "We consider this initial reporting year to be developmental. Next year's certification will focus on progress and setting standards. After that, the Patient Safety Commission's Reporting Program will be certified according to objective standards."

The complete report, "Public Health Officer Certification Report 2006" (PDF) and more information is on the Patient Safety Commission Web site.