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How Safe Is Our Health Care System?

Tracking Errors


Charels Mowll, Fellow of American College of Healthcare Executives, Executive Vice President, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL.

Frederick J. Heigel, Director, Bureau of Hospital and Primary Care Services, New York State Department of Health, Troy, NY.

Anna T. Polk, Program Administrator, Risk Management Program, Florida Agency for Health Care Administration, Tallahassee, FL.

Charles Mowll reviewed the building blocks of a system to reduce events causing serious harm. Data for this presentation were based on a survey conducted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Participants also were referred to a survey conducted by The National Academy for State Health Policy that included responses from all States and not just the 32 States represented by the following findings:

Uniform definition/taxonomy: Based on the JCAHO survey, the following number of States reported collecting data on the following events:

  • Unexpected patient deaths (13).
  • Wrong site surgery (5).
  • Infant abduction and wrong infant discharge (6).
  • Rape (9).
  • Hemolytic transfusion reaction (6).
  • Major loss function due to treatment or surgery (5).

Thorough and complete event identification process: Sixteen States reported that they had a State law requiring reporting of sentinel events.

Centralized data repository for reporting: Information is maintained in databases by 12 States.

Intensive assessment of root-cause analysis of events: In States requiring reporting of sentinel events, reportable information typically includes data on the event itself, a corrective action plan, and confirmation that the corrective actions were taken. Root-cause analysis is not uniformly required.

Corrective actions implemented: Only one State requires a corrective action plan. Eighteen States and the District of Columbia indicated that a followup is done to ensure corrective action.

Lessons learned based on aggregate data analysis: To date, State emphasis has been to monitor the individual provider's response to a sentinel event. Only three States proactively release sentinel event information to the public.

Monitoring and oversight process: Five States indicated in the JCAHO survey that a State survey is done in all cases; 13 States indicated that a State survey is done in some cases.

Frederick Heigel reported on the New York Patient Occurrence Reporting and Tracking System (NYPORTS), New York's mandatory system for reporting adverse events. Components of the system include:

  • Reportable events are clearly defined in an "includes/excludes list" used by 260 hospitals.
  • Approximately 20,000 reports are received annually.
  • Definitions of events are consistent with those used by JCAHO.

NYPORTS is linked with other State reporting systems to reduce duplication of effort (e.g., Blood Resource Incident Reporting System, Perinatal Data System, Cardiac Reporting System, Office of Mental Health Reporting System). Based on the specific type of occurrence, either a long or short form is completed and submitted to the State. To encourage reporting by facilities, NYPORTS:

  • Protects confidentiality and creates punitive sanctions for failure to report.
  • Builds a database to provide useful information that facilities can access directly.
  • Shares best practices.

NYPORTS has developed several strategies to address concerns about underreporting. The system is linked to surveillance and complaint systems in the State, and the State follows up on media inquiries. Routine analysis of data variations is made to validate reports.

A balance must be reached between discovery and disclosure of the data. New York provides full disclosure of reports to the Department of Health (DOH) but no disclosure to the public. Hospital-specific aggregate data and findings resulting from DOH activities are shared with the public.

NYPORTS has identified several strategies to make their mandatory systems work effectively to reduce errors and improve patient care:

  • Continued analysis and monitoring of reporting over time.
  • Continuing education and feedback to facilities.
  • Involvement of regional councils to analyze data and conduct focused studies.
  • Investigations of serious occurrences by the Department of Health.
  • Availability of aggregate data to assist hospitals in quality improvement efforts.
  • Issuing of advisories to hospitals regarding best practices.

Anna Polk discussed Florida's Comprehensive Medical Malpractice Reform Act of 1985 and its effect on reducing medical errors. According to the statute, hospitals are required to implement risk-management programs with State oversight and an incident-reporting system. The risk-management program must:

  • Investigate and analyze the frequency and causes of general and specific types of adverse incidents to patients.
  • Educate facility staff and agents.
  • Analyze patient grievances relating to patient care and the quality of patient care.

With respect to a hospital's incident-reporting system, the facility must submit to the State an annual report of all adverse incidents and malpractice actions (new, pending, and closed) for the reporting period. Florida has instituted several strategies to encourage reporting:

  • Confidentiality.
  • Risk-management system review.
  • Possible sanctions.
  • Distribution of summary data.
  • Web site information.
  • Counseling, education, technical assistance.

The Florida Sterling Council, formed to encourage continuous quality assessment and quality improvement throughout business, education, and government in the State, defined several processes for why total quality fails:

  • Not enough commitment on everyone's part to change.
  • Measuring what is easy to measure rather than what is valid.
  • Looking for a quick-fix, short-term focus.
  • Confusing cost reduction with quality improvement.
  • Lack of connection of quality goals to business strategies.

The active involvement of hospital-based risk managers is key to the success of Florida's program. They must be skilled in conducting expedient, objective, and thorough investigations. Equally important, they must facilitate close working relationships with hospital staff and providers to assure the reporting of incidents and cooperation in subsequent analyses.


Buckingham BK. When laparoscopic gallbladder surgery goes wrong. TRAIL 1999 May.

Florida Agency for Health Care Administration. Annual Report of Incidents. Tallahassee (FL): The Agency; 1998 Nov.

Florida Agency for Health Care Administration. Directions for completing code 15 reports for Florida hospitals, ambulatory surgical centers, and HMOs. Tallahassee (FL): The Agency; 1998 Nov.

Florida Agency for Health Care Administration. Code 15 report. Tallahassee (FL): The Agency; 1998 Dec.

Florida Agency for Health Care Administration. 24 hour Report. Tallahassee (FL): The Agency; 1998 Dec.

Florida Agency for Health Care Administration. Risk management: most frequently reported procedures resulting in patient injuries in 1998 Tallahassee (FL): The Agency; 1998 Nov.

Florida Agency for Health Care Administration. Risk management: most frequently reported injuries. Tallahassee (FL): The Agency; 1998 Nov.

Florida Agency for Health Care Administration. Risk management: reported malpractice claims by district. Tallahassee (FL): The Agency; 1998 Dec.

Florida Agency for Health Care Administration. Directions for completing the annual report of incidents for Florida hospitals, ambulatory surgical centers, and HMO's. Tallahassee (FL): The Agency; 1998 Nov.

Gergin A, Healthcare's deadly secret: accident routinely happen. Philadelphia Inquirer 1999;12 Sep-15 Sep.

Hawkes TF. The second reformation: Florida's medical malpractice law. Florida State University Law Review 1995;13(747):746-59.

Health Providers Network: NYPORTS, News and Alert. Albany (NY): The Network; 1999 Jun.

Joint Commission on Accreditation of Health Care. Sentinel Event State survey. The Joint Commission; 1998 May.

MCPhee SJ. Maximizing the benefits of autopsy for clinicians and families: what needs to be done. Arch Pathol Lab Med 1996;120(8): 743-8

New York Department of Public Health: Public health law. Albany (NY): The Department; 1998 Apr.

Palmer RG. Altered and lost medical records. TRAIL 1999 May

State of Florida. Health Care Risk Manager Licensure Statutes (1998) ss. 395.10971-395.10975.

State of Florida. Related Health Care Risk Manager Statutes (1998) s.395.0197, s.641.55.

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