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Editorial: Make medical error reporting mandatory

The (Bend) Bulletin, April 18:

Medicine is science, training and art performed by humans. Mistakes happen.

Oregon’s laws and rules don’t do enough to ensure there are fewer mistakes. Reporting medical errors should not be voluntary.

Nobody really knows how many medical errors there are every year. Instead, there are national estimates. And those estimates keep going up.

Back in 1999, the seminal report “To Err is Human” from the Institute of Medicine said that up to 98,000 people a year die because of mistakes in hospitals. Then in 2010, a Health and Human Services report said poor care contributed to the death of 180,000 patients a year who were in hospitals and on Medicare. And in 2013, The Journal of Patient Safety reported that the number might be 210,000 patients to 440,000 patients each year die because of things that happened in hospitals that could have been prevented.

Concern about patient safety prompted the Oregon Legislature in 2003 to form the Oregon Patient Safety Commission. It was designed from the beginning, though, to be voluntary. Doctors, nursing homes, pharmacies, medical clinics and hospitals don’t have to report their mistakes. There are no penalties.

It is important here to note that there are critical protections in place to ensure that any submitted information is confidential and secure from subpoena.

What the commission tries to do with the data that it does get is look for trends, identify causes and suggest procedures and practices to ensure the mistakes don’t happen again. But if participation is only voluntary, the commission and Oregonians don’t know two things. They don’t truly know how bad Oregon’s problems are with mistakes. And they don’t know if the commission’s efforts are focused on the right things.

The Oregon Patient Safety Commission announced this week it is working on rules for mediating disputes over medical errors. It’s a kind of limited malpractice reform produced by the Legislature. Patients and doctors can go into a confidential mediation process to settle disputes.

It is better than nothing. But what’s interesting about this work assigned to the patient safety commission is it really isn’t about reducing medical errors. It’s about creating a better process for handling mistakes after they’ve already happened.

We can’t fault Kitzhaber and the Legislature for handing the Oregon Patient Safety Commission some work to do on medical malpractice reform. But if Oregon is serious about reducing medical errors, they should make reporting errors mandatory.


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