How safe are we?

It may not be a crystal ball, but patients can clearly see the safety record of area hospitals and how likely they are to emerge unscathed from a medical procedure, thanks to a new online database.

Health care facilities statewide have been required by law since 2006 to report medical errors that include 28 types of mistakes, referred to as adverse events. Now citizens have access to the data on Washington State Department of Health’s Web site reported from June 2006 to March of this year.

The process focuses on quality improvement rather than discipline, said state Secretary of Health Mary Selecky in a statement released last week.

“Patient safety is our priority, and this information is a helpful tool,” said Selecky. “It helps facilities spot problems and find solutions to improve patient safety.” The system focuses on quality improvements through a root-cause analysis required of health care facilities when a medical error occurs. The procedure walks the medical team involved back through the mistake and puts a plan in place for future success.

The health department said access to the data is not intended to compare hospitals; it is used as a tool by facilities to improve surgical actions.

Since the law was enacted, 652 events have been reported by 60 hospitals. Of the adverse events, 402 were pressure ulcers that resulted from being immobilized too long in bed, which in extreme cases can lead to death. Since the reporting first began, hospitals have reduced the number of pressure ulcers, according the state health department.

Of the 137 beds at Skagit Valley Hospital in Mount Vernon, there have been 11 adverse events reported since 2006 that include: two cases of foreign objects left inside patients, one wrong blood product, three pressure ulcers, one wrong site surgery and four falls resulting in death or disability.

Joyce Cardinal, director of quality for Skagit Valley Hospital, said monthly safety reports and the paperwork that goes with them are sometimes overwhelming, yet the process has been beneficial. The root-cause analysis is now used following near misses at Skagit Valley Hospital as well, said Cardinal.

“It’s been a good process,” she said. “It’s given us more structure.”

Cardinal said Skagit Valley Hospital has had a marked decrease in hospital acquired pressure sores since the push for more transparency began in 2005.

“We really feel the public has the right to know,” she said.

Providence Regional Medical Center in Everett reported 24 cases at its 372- bed facility that include: one wrong site, five wrong surgical procedures, eight retained objects, two pressure sores, seven falls that have resulted in death or disability and one case when restraints were needed.

Cascade Valley Hospital in Arlington has 48 beds and reported one medication error in the last four years since the law was enacted.

Chief Executive Officer W. Clark Jones with Cascade said the public should keep in mind the size of the medical facility when viewing the record of adverse events on the state health department’s Web site.

“A larger hospital is going to have many more mistakes,” said Jones.

For instance, Harborview Medical Center in Seattle has 860 beds and has reported 27 pressure sores on patients during the last four years. Patients may stay three to four weeks at Harborview compared to just three to four days at Cascade Valley Hospital, noted Jones.

Still, he said they attribute their good safety record to it being a smaller institution, staff who have worked with each other for many years, a structure that focuses on safety and one more thing:

“This is a small town. We’re taking care of our neighbors,” said Clark. “We know these people.”

To view the state Department of Health database, visit www.doh.wa.gov and click on adverse events and medical errors.

Adverse events reported June 2006 – March 2010