HealthLawProf Blog

Editor: Katharine Van Tassel
Creighton University School of Law

Thursday, May 12, 2005

"Surgeons' Errors Often Unreported"

That's the headline on a recent article in the Seattle Post-Intelligencer, summarized by the CDC Public Health Law News as follows:

In many states, severe patient-care errors in hospitals may not get investigated quickly by state agencies, and patient advocates are pushing for faster action. In Washington State, for example, when a hospital employee amputates the wrong limb or makes a fatal medication error, the hospital must file a report to the state within two days. But that's where the system comes to a halt. Sometimes, such reports sit in computer databases for years. "It's absolutely not aggressive enough," said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. "Errors are not dealt with in a speedy manner. We would never put up with this if it was an airline crash or train accident," he said. Meanwhile, state health departments are trying to craft policies that increase hospitals' accountability while also avoiding a punitive approach that discourages reporting. State agencies often do not have the resources to vigorously investigate adverse events, or even to inspect hospitals on a reasonably frequent schedule. In Washington, for example, hospitals are inspected only about every 20 to 21 months, and sometimes less frequently. Critics say patient safety regulations for hospitals all across the U.S. are largely archaic. "They've (the regulations) been there a long time and are probably very spottily carried out because there's not a mechanism for enforcement," said Kala Ladenheim, a health policy analyst for the National Conference of State Legislatures. Fewer than half the states even require hospitals to report "adverse events," she said.

And from their Northwest corridor neighbor state comes this report of safety-enforcement laxity from The Oregonian:

As Australia investigates patient deaths linked to former Oregon surgeon Jayant M. Patel, a question echoes half a world away: How could Patel operate here for more than a decade before state officials cited him for "gross or repeated acts of negligence?"

Who's watching what doctors do to patients?

The answer, many health experts say, is that few hospitals or doctors' groups have solid systems to track every surgery and highlight patterns of problems. Although doctors now have amazingly good tools to measure cells and genes, the study of what happens in U.S. operating rooms remains surprisingly unscientific.

It's a sad, sad tale of seemingly glacial oversight and enforcement efforts, and well worth reading for its discussion of the systemic gaps in reporting requirements that make it difficult to weed out the "bad apples," let alone to identify and deal with less obvious bad practices and bad practitioners.  [tm]

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