The District government will investigate city hospitals and clinics to determine whether they are withholding reports of medical errors that killed, injured or sickened patients, a top city official testified Wednesday.
“Unless we improve the reporting technology … the process will not serve to improve either the analysis or the feedback to the reporting health care facility,” Department of Health executive Feseha Woldu told a D.C. Council hearing called to examine “adverse events” in hospitals and clinics.
An Examiner story Tuesday said there were 529 reported incidents in D.C. in the 12 months ending in June 2008. The human toll: at least 14 people dead and scores of others maimed or injured. The incidents were collected in the first-ever adverse-event report, required under D.C. law to track medical malpractice.
Among the errors detailed were a cancer patient who had the wrong breast operated on because of a clerical error, a patient who died when his ventilator failed, and numerous instances when sponges, catheters and even needles were sewn up inside of patients.
The report also found, though, that many hospitals and nursing homes hadn’t handed over information on doctors’ errors and machine failures. At Wednesday’s hearing, convened by Councilman David Catania, independent-at large, experts differed on whether that meant the offending clinics had nothing to report or were ignoring the law.
Woldu argued for the latter, but D.C. Hospital Association President Robert Malson, whose group represents doctors and hospitals in the District, said that the silent hospitals and clinics may “simply … not have any ‘never events’ to report.’ ”
Ten of 15 hospitals complied with reporting requirements, Malson said.
“For a brand-new mandate, this is good compliance,” he said.
Frederick Finelli, chairman of the D.C. Board of Medicine, said Wednesday that the malpractice report was a good first step.
“However, we all know how easy it is to file a report away and move on to the next big issue,” Finelli said. “We need to act on these recommendations in an organized fashion.”
