- Associated Press - Thursday, June 9, 2016

BEND, Ore. (AP) - Only 12.6 percent of eligible Oregon facilities voluntarily reported medical mistakes in 2015, according to a new report.

All 59 Oregon hospitals submitted error reports, but less than 1 percent of pharmacies participated, The Bulletin (https://bit.ly/1Xck5lL ) .

The Oregon Patient Safety Commission has collected error reports since 2006. State lawmakers asked the commission to publish annual reports on the types of mistakes that occurred and what contributed to them.

Carrie Parrish, who runs the commission’s reporting program, said hospitals have been reporting adverse events for longer than other types of facilities and participate at much higher rates in the voluntary reporting program. The commission also collects information from outpatient surgery centers and nursing facilities. About a third of those facilities sent in reports last year.

Parrish said she’s not shocked by the low number of organizations sending reports. The commission mostly focused on educating the places that do send reports on making them more useful, she said.

Parrish couldn’t explain why so few pharmacies participated.

“Pharmacies really aren’t picking it up in the same way we’re seeing every other segment consistently over time improve their engagement with the program,” she said.

According to a study by Johns Hopkins University School of Medicine researchers, medical errors are now believed to be the third-leading cause of death in the U.S.

Oregon’s program collects information on mistakes of all severity levels, from those that merely create the possibility of harm to those that result in death.

Of the mistakes reported last year, 48 percent led to serious harm or death. Six of the deaths were patient suicides, up from five in 2014. The commission is working on a report to help health care facilities assess the risk of suicide or self-harm, said Parrish.

The Legislature set guidelines to determine whether the reports are of “acceptable quality” — for example, whether they include a plan to prevent future mistakes and identify the root causes of errors.

“Ultimately, the goal is that we can see something go wrong in one place and we can learn from it before it happens to us,” explained Parrish.

There has been a significant improvement in report quality this year, especially among hospitals, Parish said.

“That’s really reassuring to us,” she said.


Information from: The Bulletin, https://www.bendbulletin.com



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