Massachusetts acute care hospitals reported 62 serious safety violations related to surgical care in 2008, according to a Massachusetts Department of Public Health report. The newly released report is the first ever documentation of the state’s hospital-specific adverse events.
The report, based on the National Quality Forum’s categorization of serious reportable events, includes surgical-related errors such as wrong-site, wrong-patient and wrong-procedure surgeries, foreign objects left in patients and immediate post-op death of ASA Class I patients. Of the 338 reported SREs across all patient care categories, 32 incidences of retained foreign objects and 24 wrong-site surgeries trailed only 224 patient falls as the most frequently occurring errors. Five wrong procedures and 1 wrong-patient surgery were documented.
DPH officials note that hospitals have always been required to submit patient safety data, but 2008 was the first year Massachusetts used a reporting system based on NQF standards. They point out that this initial reporting year will serve as a baseline to assess future error reporting, and cannot be used to judge the quality of care at specific hospitals.
"This is a very important step we are taking for patient safety in Massachusetts," says DPH Commissioner John Auerbach. "This new reporting system — and the data collected — will provide a roadmap for hospitals, healthcare providers and public health professionals to follow as we work together to prevent many of these errors in the future."
—Daniel Cook
