In 2008, the Oregon Patient Safety Commission (OPSC) set a simple goal for itself – become the safest health care delivery system in the United States. The OPSC set out procedures and standards to measure progress in hospitals across the state. Noting that Oregon’s level of care was only “average” by any measurement, the OPSC’s objective was to use these standards to improve patient safety.
The standards asked five main questions:
- Can we demonstrate that we are eliminating preventable harm events?
- Are we using evidence-based best practices?
- Are we assessing risk and learning from experience?
- Do we have a culture that supports learning and improvement?
- Are we working to create connected systems of care?
In its recent report, the OPSC cited improvement in three of the five categories: using an evidence-based practice, creating a culture of learning and creating connected systems of care. However, the report found no improvement in hospitals eliminating preventable harm events.
Fifty-six of the 58 hospitals in Oregon reported data to the Commission, representing all but one percent of the total hospital care delivered in the state.
Measuring Adverse Events
The report defined an “adverse event” as “any unanticipated, usually preventable consequence of patient care that results in death or serious physical injury.” From 2006, the first year the data was tracked, until 2009, the OPSC received 383 reports of adverse events.
In the first six months of 2010, the Commission received only 41 reports of adverse events. There were 55 reports during the same period in 2009. Though this data seems to suggest that hospitals are improving in preventing some errors, the OPSC believes that these events are actuallyunderreported by hospitals.
Three main types of adverse events made up half of the reported events during 2009: 1) falls (19 percent), 2) retained objects or instruments left in patients after surgery (15 percent), 3) medication errors (12 percent).
Working With an Attorney
Hospitals that participated in this program are supposed to report adverse events to the OPSC and to the patient. However, a recent report in DOTmed News indicates that in 2009 only half of the adverse events were reported to the patient, meaning the patient cannot always rely on a hospital to disclose harmful events to the patient.
As a result, it is important to work with an experienced Oregon medical malpractice attorney if you believe you have been the victim of medical malpractice at the hands of any doctor or hospital staff. You only have a limited amount of time to file a claim for your injuries.