Detailed hospital reports vital

It's difficult enough for many people to negotiate the health-care system. Between insurers' cost limits and preferred providers lists by which patients must abide, there is now concern that some Utah hospitals may be underreporting medical mistakes — issues that impact patient safety and outcomes.

If this issue had been raised by a "think tank" in some far-off place, the Deseret Morning News most likely wouldn't be lifting it up to readers. When such a concern is raised by Utah Department of Health director Dr. Scott Williams, we take notice.

Williams, himself a pediatrician, is convinced that the medical mistakes reported to state health authorities by Utah hospitals are incomplete. That's disturbing because medical errors, at a minimum, compromise patient safety. In the worst cases, patients die.

Under health department regulations created two years ago, hospitals are supposed to report sentinel events. Those events include patient deaths, loss of function, wrong-site (or wrong-patient) surgery, abductions or assaults on patients and patient suicide.

From October 2002 to October 2003, Utah hospitals reported a total of 34 adverse "sentinel" events, including deaths. Fifteen patients died, six lost function; five wrong-site surgeries were performed and one patient suicide was reported. Except for one case, the events occurred in an urban hospital. Meanwhile, a recent national report had predicted that 300 patients would die within a given year.

Williams believes the true number lies somewhere in between.

This reporting requirement was not created to besmirch the reputation of any health-care facility. Rather, it is intended to track errors and determine how they can best be prevented, if at all.

If the reporting was complete and accurate, it would help consumers make more educated decisions about where they will seek health care. Hospitals that operate safely should have little to fear from accurate reporting. Statistics are reported in proper context, and facilities have an opportunity to explain incidents and numbers that would appear alarming to the general public.

The state health department appears to have given hospitals sufficient time to implement procedures and programs to help reduce mistakes. For instance, the health department gave all hospitals until fall 2004 to implement programs to reduce adverse drug events.

Moreover, Utah takes a collaborative approach to addressing medical errors by inviting the hospitals to partner in the effort to report errors and fix root causes. That seems more productive than a state agency simply setting standards and lowering the regulatory hammer when hospitals don't perform well.

Hospitals that don't report completely or accurately should be aware that the information can come to light in other ways, such as through the health department's own record checking and civil lawsuits. Given the health department's collaborative approach to this issue, hospitals should make all attempts to fully report medical errors and be open to recommendations to reduce their incidence.