• 29
  • September
    2010

In the next two posts, we will talk about medical error reporting and the deficiencies within the system. This post will explain how one man's death revealed flaws in the way the system defines medical errors. Currently, 27 states require hospitals and other medical facilities to report serious medical errors to their state department of health. The state departments publish the errors on state websites in an effort to encourage facilities to fix problems and in order to allow the public to make better informed decisions.

Many hospitals evade reporting their errors because of flexible definitions. One man's death that resulted from a medical mistake exemplifies what can fall through the cracks of the system. Hours after going in for an outpatient arthroscopic shoulder surgery, a man we will refer to as Mr. B suffered brain damage because of an incorrect management of pain medication. Mr. B consequently was put on life support and passed away two days later.

The error that caused Mr. B's death was not categorized by the hospital or that state's department of health as a "reportable error." The medical facility where Mr. B's outpatient procedure took place decided that the facts around his death did not meet any of the state's 28 definitions for a "serious reportable event." The facts of his death fell around the provided definitions. For example, had Mr. B passed away within 24 hours of his operation, the facts would have met the category "intraoperative or immediately postoperative death." Tragically, Mr. B's breathing stopped for a period of time, and he was revived. The lack of oxygen caused brain damage but not his death. 

Since Mr. B's case did not fit any of the state's medical error definitions, the case was not made public by the state health department. As a result, the record of Mr. B's hospital remained clean despite the error. The hospital where Mr. B's outpatient surgery occurred has had a clean record on the reporting site for the past four years. In the next post, we will discuss how such a mistake is missed within the reporting system, and we will discuss the systems most serious weaknesses.

Source: Seattlepi.com, "Despite Law, Medical Errors Likely Go Unreported," Eric Nalder, 9/27/10