The Springfield News-Leader recently reported on the tragic story of a 34 year-old man who hung himself while hospitalized for depression. Hospitals call this a “never event,” a tragedy that normally should not happen in a health care facility. This could also include major medication errors, surgeries performed incorrectly or on the wrong patient, or a death during an otherwise ordinary procedure. The man’s father reached a confidential settlement with the hospital over his son’s death, but also says he never received an apology from the hospital. His case illustrates the problem of tracking and obtaining information on such “never events” in hospitals in Missouri.
Few states require reporting of adverse events by hospital and other medical providers, with most having a system of voluntary reporting. Few states allow public disclosure of data related to any such reports, making it difficult for people injured due to medication errors and other hospital mishaps to obtain information they may need to protect their rights.
Hospitals and other providers have generally fought efforts to mandate reporting and to make information available to the public. Concerns over liability, and of course litigation, lead the objections. An official with the federal Agency for Healthcare Research and Quality (AHRQ) describes a “no-blame culture” that encourages voluntary reporting of errors by removing the immediate fear of liability. It would seem that any reports or documentation that contain information relevant to a specific patient’s claim for damages ought to be subject to discovery by an attorney. Patient privacy laws may hinder error reporting, as medical providers cannot disclose confidential patient information except in specific circumstances. Safeguards exist, however, that would allow reporting without violating such laws.
Both federal and state laws have attempted to address these issues. While they may have made positive steps towards greater patient safety, they still do not allow access to information that could help an injured patient, nor do they help the government analyze broad samples of data. The federal Patient Safety and Quality Improvement Act of 2005 (PSQIA) was intended to provide for widespread sharing of error information by medical providers and government officials. The law allowed the designation of patient safety organizations (PSO’s) in each state to collect data from hospitals and other providers on adverse events and unsafe conditions. The PSQIA does not allow disclosure of any of this information to the public, and any disclosure is strictly regulated. It also does not require reporting of errors, instead making all reporting voluntary. The AHRQ is supposed to review data collected by the PSO’s, but with only voluntary reporting it cannot perform any sort of meaningful analysis.
Missouri’s PSO, the Missouri Center for Patient Safety, also does not require error reporting, but accepts voluntary reports. It may be able to do some amount of data analysis, but it is difficult to see how the system can achieve much in the way of comprehensive improvements with only voluntary reporting. As for patients seeking compensation for injuries caused by medication errors or other malpractice, for now they must stick with litigation and the discovery process.
People who have suffered injury due to a medication error in a pharmacy or hospital may be entitled to compensation for their damages. For a free and confidential consultation with an experienced Kansas City pharmacy error lawyer, contact Doug Horn at Horn Law today through our website or at (816) 795-7500.
The Patient Safety and Quality Improvement Act of 2005, Agency for Healthcare Research and Quality
Missouri Center for Patient Safety home page