Patient Safety Authority 2012 Annual Report to the Legislature
Pennsylvania’s Patient Safety Authority is required by law to report to the Pennsylvania Legislature every year. The newest report, for 2012, is currently being circulated.
I take great pride in the work of the Patient Safety Authority because of my role in this important organization coming into existence. When I was President of the Trial Lawyers in 2001, I insisted that any change in the laws with respect to medical liability, include the creation of a Patient Safety Authority. The Institute of Medicine, speaking to the healthcare community and others in 1999, recommended a national Patients Safety Authority.
The Institute of Medicine and others in the healthcare field were appalled at the number of preventable deaths in hospitals which were taking place on a regular basis. The number of deaths was equivalent to two 747’s crashing each month with the loss of all life aboard.
The report, which should become available online, notes that the Patient Safety Authority is an independent state agency established under Act 13 of 2002, the Medical Care Availability and Reduction of Error Act. “It is charged with taking steps to reduce and eliminate medical errors through the collection of data, identification of problems, and recommendations of solutions that promote patient safety in hospitals, ambulatory surgical facilities, birthing centers, and abortion facilities.”
What is unique about this year’s work is the development of a strategic plan which many of us on the Patient Safety Authority have been pushing very hard for. The Patient Safety Authority issues Advisories to hospitals throughout the state and has an important Patient Safety Liaison program to coordinate developments between the Patient Safety Authority and hospitals. Unfortunately, many hospitals have a long way to go on the road to patient safety, but the Patient Safety Authority is working to educate and inform those who work in and around the hospital community.
North Central Pennsylvania continues to be the highest reporting part of the state with respect to the number of reports submitted. There are those who say that this merely means that hospitals in North Central Pennsylvania are better at reporting or perhaps more honest about so doing. Others suggest that perhaps there is a pattern suggesting that North Central Pennsylvania needs to be more attentive to safety in hospitals.
One of the current issues for the Patient Safety Authority is that there is a great reluctance to issue “report cards” for hospitals. Although information is collected on a per hospital basis, the Patient Safety Authority only distributes information regionally. It is my view that the Patient Safety Authority needs to work towards developing report cards which will provide an incentive for hospitals to do better. Ultimately, government regulation or even government encouragement will do little good unless consumers are allowed their day in court and unless consumers are free to choose better hospitals. Patients who seek hospital services cannot know the best hospitals unless information is transparent and made available as to which hospitals are having problems and which are not. Some of this information is already available thanks to Medicare and even organizations such as Consumer Reports are now printing data about hospitals based upon information obtained both privately and publically.
The Patient Safety Authority risks being left in the dust by patient safety developments unless it is able to look at reports from hospitals and figure out whether it means that those hospitals are simply better at reporting problems or whether they have more problems that are unacceptable. Act 52 in Pennsylvania has attempted to establish benchmarks for infections. In other words, once it is known how many infections emanate from the hospital, it is possible to determine what is an “acceptable” number of infections for that particular institution. There are those who say that the infection rate in hospitals could be and should be reduced to zero. Infections are a major cause of increased healthcare costs. When a person contracts an infection in the hospital, the cost to fight that infection can be catastrophic.
There is no question that the ultimate answer to rising healthcare costs in America is to make hospitals safer. I was once told by the head of a major hospital in Pennsylvania that “Patient safety is just good business. It helps our bottom line.” He is absolutely right and we became collaborators in the effort to enhance patient safety in hospitals.
The Patient Safety Authority has continued to make tireless efforts in the area of training and education. Attendance at educational events has continued to increase. Collaborative efforts between the Patient Safety Authority, facilities and other organizations is a good thing. Unfortunately, the Patient Safety Authority receives very few anonymous reports. People who work at hospitals are still afraid to report anonymously for fear of retaliation. Stronger anti-retaliation and anti-blacklisting language is necessary in order to ensure that people who work in hospitals can feel free to tell the truth.
As the report by the Patient Safety Authority to the Legislature will show, there have been many strides in patient safety awareness. The addendums to the report, while dense from a statistical point of view, are certainly worth reading for anyone who is interested in patient safety and the problems encountered in hospitals. For example, reports for event, types and admission for 2012 show that the greatest number of errors in hospitals is errors related to procedures/treatment tests at 22%. That is followed closely by medication errors at 18%, complications of procedures/treatment/tests at 15% and skin integrity at 15%
Consumers and those who pay hospital bills will continue to drive patient safety, to reduce unnecessary medical errors and therefore to reduce the cost of healthcare in the United States. Although much credit goes to the Patient Safety Authority, there is much work ahead of us.
Clifford A. Rieders, Esquire
Rieders, Travis, Humphrey,
161 West Third Street
Williamsport , PA 17701
(570) 323-8711 (telephone)
(570) 323-4192 (facsimile)
Cliff Rieders, who practices law in Williamsport, is Past President of the Pennsylvania Trial Lawyers Association and a member of the Pennsylvania Patient Safety Authority. None of the opinions expressed necessarily represent the views of these organizations.