Pharmacy Errors Seldom Get Reported

Oregon Gov Site, Sep 02, 2008

Families rarely hear about serious errors.

A state program aimed at reducing medical mistakes is having trouble getting pharmacies to voluntarily report serious errors, which national studies suggest happen in as many as one in 50 prescriptions.

The Oregon Patient Safety Commission not only asks hospitals to report their medical errors to the commission; hospitals that agree to participate in the voluntary reporting program also are required by statute to report serious adverse events to patients or their families in writing. They don’t do that very often, according to commission administrator Jim Dameron. Dameron estimates that in 2007 Oregon hospitals abided by the state’s written notification policy in only about three or four cases out of 10.

He says that’s what the hospitals themselves are telling him. In 2006, he says, the number of hospitals willing to notify patients or their families was as high as seven in 10. As to why more hospitals aren’t complying with the notification statute, which guarantees hospitals that their notification letters cannot be used against them in court, Dameron says, “Usually they say they learned of the event too late or the patient died and had no family.” Larry Wobbrock, a Portland medical malpractice attorney, says even four out of 10 sounds high to him.
“I’ve never seen any hospitals tell anybody, ‘We’ve made a mistake’ – in writing or otherwise – in 31 years,” Wobbrock says.

Wobbrock says that even if the letter from the hospital can’t be used in court, it still could alert patients or their families that there is something they might want to pursue with an attorney. “They probably don’t want the patients to know they’ve been malpracticed on,” Wobbrock says. “It doesn’t mean you couldn’t prove the case otherwise.” Dameron says the commission’s statutes leave the hospitals room to notify patients without disclosing too much. “A letter doesn’t have to say ‘We did this horrible thing, please sue us,’ ” Dameron says. “It can
say, ‘We’re committed to understanding what happened. We’re sorry it happened, and we’ll let you know.’ ” Gwen Dayton, general counsel for the Oregon Association of Hospitals and Health Systems,

says that the association supported putting the written disclosure notice.
“What I hear is hospitals are engaged in trying to do it,” Dayton says of notifying patients and their families. Dameron says that the voluntary nature of the commission means he has little leverage that would force hospitals to comply with the notification statute. And that places Dameron in a delicate role in dealing with the hospitals. “There’s that sweet tension of how do you hold them accountable when they can just say, ‘Enough already,’ ” Dameron says.

Read more here
http://www.oregon.gov/OPSC/docs/News
/Pharmacy-mistakes-seldom-reported-Trib021508.pdf

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