Someone needs to oversee patient-safety issues

I'm curious about state government's reluctance to provide funding for a full-time position in the Utah Department of Health for someone to oversee patient safety issues at hospitals and surgical centers.

This week, the Utah Department of Health and other officials unveiled a several-pronged plan to investigate risk factors and reasons for deaths attributed to medications and illicit drugs. The goal is to reduce them. The Legislature funded a position to help those efforts.

I'm not complaining about that, by the way. Utah leads the nation in non-medicinal use of medications. And about 470 people died last year because of prescription, over-the-counter and illicit drugs, most of those deaths attributed to legal drugs.

But no one knows exactly how many patients die each year because of patient safety issues — man- or system-caused — much less how many people have treatment complications that extend hospital stays, increase costs of care and potentially change lives.

Health director Dr. David Sundwall said if he had to hazard a guess, patient safety just isn't sexy enough, and that's why the department's request goes unfunded. It doesn't make headlines or lead TV newscasts the way overdose deaths do.

I think he's probably right. But I think rulemakers themselves have made it uninteresting simply by making it unavailable. Unlike many states, which publish overviews and particulars on patient safety lapses, Utah guards the information like it was the combination to the state piggy bank.

Hospitals and surgery centers are supposed to report serious patient "events" to the health department, which promises, in return, to keep it to itself. It appears, though, that some facilities skip a step. They just keep the information to themselves.

It's hard to get too upset about patient safety issues when you don't know whether there are any.

Health officials aren't too sure they really know, either. The state hears about an average of 35 sentinel events a year. The Institute of Medicine conservatively figures that deaths that involved some sort of patient-care event average about 300 in Utah a year. That estimate doesn't include cases that stopped short of death.

Patient-harm events usually have nothing to do with human error, the experts say. It is an umbrella that includes system failures and things that happen for unknown reasons, as well as mistakes.