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Medical errors underreported. Why? System voluntary

Medical errors underreported. Why? System voluntary »Play Video

PORTLAND, Ore. – The latest way patients can supposedly research medical mistakes made big headlines last week.

It's a new watchdog website that right now shows 15 violations at Portland hospitals and 82 across Oregon. The trouble is the state has a much tougher standard for when errors need to be reported.

Hospitalinspections.org details problems that were widely reported and others that weren't.

But even though the data comes directly from the Centers for Medicare & Medicaid, the records are incomplete. The actual number of hospital mistakes is higher than the 15 listed for Portland hospitals – a lot higher.

Oregon hospitals are supposed to report medical mistakes to a state agency called the Oregon Patient Safety Commission.

The commission expected at least 29 mistakes at Oregon Health & Science University last year, 25 at Providence St. Vincent, 20 at Providence Portland and 16 at Legacy Emanuel Medical Center.

None of the hospitals hit its reporting goal, which is based on the number of patients it handles. Specific numbers are not a public record but KATU News was told the hospitals came close. 

It's not because they aren't having many events.

"You can look at all the literature that’s out there, and we have very solid evidence that underreporting is a big problem," said Bethany Walmsley of the Oregon Patient Safety Commission.

The commission was set up by the Legislature a few years ago as a way to use data about how mistakes happen to help hospitals avoid more. But it's a voluntary program.

"I think the reason you've seen health systems, particularly in the metropolitan area, not submit the total number of reports is that they really haven't seen the value in the data or the database that's being built," said Dr. Chuck Kilo at OHSU.

As chief medical officer at OHSU, Kilo says different hospitals have chosen to report different kinds of mistakes. There's no standard reporting criteria.

That leaves an apple to orange dynamic. OHSU chose only to report its most serious mistakes. Another hospital may choose to report much less severe issues – say when patients were given antibiotics later than they should have been. It's difficult to draw conclusions from a mixture of different things.

"I don't think a lack of data is our primary challenge," said Kilo. "I think the Oregon Patient Safety Commission needs to go back and really try to discern why they would want to collect that data, what benefit we think it's going to provide, because health systems these days have so many requests coming to them for data or for reporting or regulatory things, I think we should be really sensitive to add more and more on to their plate."

Kilo says OHSU already reports safety data to eight different organizations.

The Oregon Patient Safety Commission says it could collect better data if it could break through a medical culture that's traditionally kept tight-lipped.

"I'm frustrated by the amount of time that it's taking to get where we want to see a lot more reporting," Walmsley said. "We are making progress across the board, but I wish I could go faster."

She said the fear of liability is a factor in underreporting, but may not be the biggest one.

The specific information gathered by the Patient Safety Commission about each mistake is confidential. It can’t be used in a lawsuit.

Oregon Gov. John Kitzhaber signed into law a bill that establishes a mediation program between patients and doctors when a mistake is made. It will be the first statewide program of its kind in the country.

One goal is to reduce malpractice lawsuits.

If you have a story for any of our On Your Side investigators, email them at investigators@katu.com.