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Hospitals report fewer ‘adverse events’

Listing of mistakes, accidents now required by law

Regional hospitals are reporting fewer surgery mistakes and serious accidents in 2008.

Called adverse events, hospitals in Washington had to begin publicly reporting more of their mistakes, ranging from pressure sores to suicides and botched surgeries, following medical liability reform legislation in 2006.

Sacred Heart Medical Center has had two reportable adverse events this year, including one surgery performed on the wrong body part and one suicide or attempted suicide by a patient in the hospital’s care.

Deaconess Medical Center also reported two events this year, both cases of serious pressure sores in February, according to state records. Pressure sores are bedsores so severe that they eat into flesh and sometimes even bone, according to standard medical definitions.

Kay Lewis, a registered nurse at Deaconess, said the hospital uses a skin assessment program during patient admissions to determine the risk of pressure ulcers. Assessments are required at every shift, raising the hospital staff’s awareness of the issue.

Valley Hospital and Medical Center has not reported an adverse event since a patient suffered pressure sores in November 2006.

Pressure sores are the most commonly reported problem statewide, with 122 reported in all of 2007 and 59 reported so far in 2008. They are most prevalent among the elderly – especially those who are frail, ill and have limited mobility, said Deaconess registered nurse Charlotte Berryman.

“And some patients are in unbearable pain, and just moving them is difficult. Especially if they refuse,” she said. “It’s a complex issue.”

The most events are reported by Harborview Medical Center in Seattle, the region’s only Level 1 Trauma Center. Because Harborview treats patients with serious injuries, illnesses and pain, it’s considered more likely to have considerably more patient problems than hospitals treating patients with less severe, life-threatening problems.

There have been two reporting events at Holy Family this year, one instance where surgeons left an object inside a patient, and one case of performing the wrong surgery.

Pullman Regional Hospitals had one case of a patient medication error.

The state requires hospitals to report problems in 28 areas.

Late last year hospitals attempted to dilute the reports. The effort backfired amid public outcry and criticism by state lawmakers who demanded the mandatory reporting requirements.

Hospital reporting requirements have been in place for eight years, though the list of 28 events was adopted in 2006.

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