Oregon announces increase in deaths from preventable medical errors

Oregon's commission that collects voluntary reports of medical errors has reported that 24 patients died of preventable errors in 2007, compared with 21 in 2006. In 2007, 54 of Oregon's 57 acute care hospitals participated--with those 54 hospitals providing 99 percent of the hospital care provided in Oregon.

Further, Oregon is the only state in the country with a completely operational voluntary reporting program.

According to The Portland Business Journal article, "Issues related to 'communication' were the most often cited fundamental cause. For those events that resulted in death, organizational factors and patient factors become very important as well."

Over the last two years, five types of adverse medical events have accounted for nearly 60 percent of the reports, specifically:

• 18.9 percent of reports were of foreign objects retained inside the body following an invasive procedure.
• Wrong site procedures comprised 10 percent of reports.
• Medication errors accounted for 10.1 percent of reports.
• 9.5 percent of events were related to falls.
• Infections were responsible for 8.8 percent of errors."

In 2003, the state Legislature passed the bill which created the patient safety commission that same year and is supported by fees collected from participating health care organizations. The reports that are collected by the commission span errors including medication mix-ups and hospital-acquired infections...as well as "near-misses" and "lessons learned." Information about these errors is  shared with members to guard against future errors.

Full article can be accessed here.