State Tracks Hospital “Adverse Events” but Doesn’t Publish Them

Wednesday, November 26, 2014

California hospitals reported 6,282 “adverse events” to the California Department of Public Health (CDPH) over the last four fiscal years—like leaving a sponge in a patient—but the agency does not provide a database to see which hospital is doing what to whom.

So NBC Bay Area helped them out.

Over the course of nine months, reporters and editors used a public records request to obtain and compile data that hospitals are required to send to the state within five days of occurrence, but which the state only publishes annually (pdf) in aggregate form. NBC put the information in a searchable database and published it along with an interactive map.  

NBC found that 63% of the broadly-defined adverse events (3,959) were Stage 3 or 4 decubitus ulcers—better known as bedsores. But second on the list with 986 events was “retention of a foreign object in a patient.”

Unlike bedsores, leaving stuff in a patient is considered a sentinel event, defined by the healthcare certification nonprofit Joint Commission as “an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof. . . . They are called ‘sentinel’ because they signal the need for immediate investigation and response.”

But, apparently, not immediate publication.

NBC also tallied 140 surgeries performed on wrong body parts, 114 instances of “death or serious disability associated with a medication error,” 107 sexual assaults on patients, 104 instances of “death or serious disability associated with the use of restraints or bedrails,” 78 attempted or successful suicides, and 66 wrong surgical procedures.

These types of events and more are categorized in the California Health and Safety Code. The definition of adverse events includes surgery, medical devices, patient protection, care management (like a drug mistake), environmental events (like an electric shock) and criminal events.

The NBC numbers are probably inaccurate in some respects and almost certainly low. Some hospitals are more vigilant about reporting incidents than others and there is some disagreement about what constitutes an adverse event. NBC found that a lot of hospitals reported just a single adverse event, while others reported hundreds. Medical experts flat out told reporters that some hospitals purposely don’t report events.

The CDPH does not have the resources to do a whole lot of policing. But it does discipline hospitals for their more egregious transgressions and regularly make the incidents public in a Top Ten list.

There is a built-in reluctance by hospitals and government to share adverse information for line-item statistical reports, without any kind of context, to a public that is likely to be judgmental. 

On the other hand, someone about to undergo surgery in Pasadena might want to know that Huntington Memorial Hospital had 22 adverse events over four years and seven of them were foreign object retentions.

–Ken Broder


To Learn More:

California Hospitals Make Hundreds of Errors Every Year, Public is Unaware (by Stephen Stock, Julie Putnam, Jeremy Carroll and Scott Pham, NBC Bay Area)

Eight Hospitals Fined $775,000 for 10 Disastrous Mistakes (by Ken Broder, AllGov California)

Retained Foreign Objects: The Cost of Leaving Something Behind (Pfiedler Enterprises)

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