Information about medical errors reported to the state are now online

Information on adverse events and medical errors in Washington hospitals and facilities is now online, the Washington State Department of Health announced Thursday.

A new Department of Health website has information for consumers and health care providers on medical errors and adverse events — and ways to prevent them, officials said.

These errors, known as adverse events, are reported by medical facilities and tracked by the state health department to improve patient safety and care at hospitals and facilities across the state, health officials said.

Under state law, hospitals and medical facilities are required to report 28 types of errors that are considered “serious reportable events” by the National Quality Forum.

The forum is a non-profit group devoted to health care quality measurement and reporting.

The new website lists adverse event reports by facility name and by date (www.doh.wa.gov/hsqa/adverseevents).

The site is not intended to be used to compare different facilities, officials said.

From June 2006 through March 2010, there have been 780 adverse events reported.

Of these events:

• 402 were pressure ulcers, also known as bed sores.

• 228 were surgical events,

• 75 were falls,

• and 20 were medication errors.

As part of the project, health facilities are asked to complete a quarterly survey about adverse events.

The results of these quarterly surveys can be found in the Adverse Event Facility by Quarter report (www.doh.wa.gov/hsqa/adverseevents/Files/QRQuarter.pdf).

The new Web tool also has frequently asked questions on adverse events; links to health resources for consumers; and information and resources to help medical facilities report, analyze, and find ways to avoid adverse events.

The 28 reportable events are:

Surgical Events

• Surgery performed on the wrong body part.
• Surgery performed on the wrong patient.
• Wrong surgical procedure performed on a patient.
• Unintended retention of a foreign object in a patient after surgery or other procedure.
• Intraoperative or immediately post-operative death in an ASA Class 1 patient.

Products or Device Events

• Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility.
• Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended.
• Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a health care facility.

Patient Protection Events

• Infant discharged to wrong person.
• Patient death or serious disability associated with patient elopement (disappearance).
• Patient suicide, or attempted suicide, resulting in serious disability, while being cared for in a health care facility.

Care Management Events

• Patient death or serious disability associated with a medication error (e.g. errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration).
• Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA- incompatible blood or blood products.
• Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in the health care facility.
• Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility.
• Patient death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinimia neonate.
• Stage 3 or 4 pressure ulcer acquired after admission to a health care facility.
• Patient death or serious disability due to spinal manipulative therapy.
• Artificial insemination with the wrong donor sperm or egg.

Environmental Events

• Patient death or serious disability associated with electric shock or elective cardioversion while being cared for in a health care facility.
• Any incident in which a line designed for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances.
• Patient death or serious disability associated with a burn incurred from any source while being cared for in a health care facility.
• Patient death or serious disability associated with a fall while being cared for in a health care facility.
• Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a health care facility.

Criminal Events

• Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider.
• Abduction of a patient of any age.
• Sexual assault on a patient within or on the grounds of a health care facility.
• Death or significant injury of a patient or staff member resulting from a physical assault (i.e. battery) that occurs within or on the grounds of a health care facility.

Tags: Medical Errors, Quality Improvement

Category: Hospital News, News, Safety