Dameron Leaves Legacy on Oregon Patient Safety

Jim Dameron retires this month from the Oregon Patient Safety Commission, which he helped create nearly a decade ago
December 15, 2010 -- Looking back on it now, there were several forces that led Jim Dameron to help create and then run Oregon's Patient Safety Commission.
In July of 2002, Dameron’s mother died from a medical error in a North Carolina hospital. Later that year, he took a job at Oregon's Health Division, drafting legislation for a medical-error reporting program. And in 2005, he became the commission’s first administrator.
Dameron will retire at the end of this month, handing the reins to Bethany Higgins, former director of quality and patient safety for Kaiser Permanente in Georgia.
“It stiffened my spine a little bit,” Dameron said about his mother’s death. “It gave me a clearer sense that this isn’t just policy wonk work. It isn’t just something that’s abstract. It’s real people being harmed in ways we could prevent if we were just a little smarter and better organized.”
It was also in 2002 that the Institute of Medicine’s report on medical errors called To Err is Human, published two years earlier, was having a profound effect across the country. It said that as many as 100,000 people died each year from preventable mistakes at hospitals.
“Most of the time, as it was in my mother’s case, it’s good people caught up in a really complex system without appropriate safeguards,” Dameron said.
That Dameron and his family chose not to sue the hospital and the surgeon who treated his mother shows how much he believes in one of the commission’s core principles: punishment alone won’t reduce medical errors.
It’s with that philosophy that the commission has kept its medical-error reporting program voluntary and confidential despite concerns that it doesn't draw enough participation. A majority of states have similar programs, though most are mandatory in some way or another.
“The evidence is that most mandatory state programs are doing no better than we are with regard to the frequency of the error reports and the utility of the program to drive change,” Dameron said from his office in downtown Portland.
The commission's board, which is comprised of  healthcare officials and consumer advocates, has had some notable success. First and foremost, its existence alone makes people more aware of medical errors, Dameron said.
The commission has promoted a surgical checklist that’s widely used  by hospitals. It’s pushed steps to reduce infections, organizes an annual conference around patient safety, and sends out a monthly newsletter with lessons learned from the confidential error reports. Earlier this year, the commission led an effort to train 300 nursing home administrators on how to investigate accidents.
At the same time, the commission struggles with a lack of industry participation and the ability to answer the fundamental question of whether it’s successful in reducing deaths.
“I lose sleep over whether the commission is working,” Dameron said. “I can point to a lot of examples where I believe we’re making a difference but I don’t have a lot of good data.”
This year, the Office of Inspector General released a report saying hospitals nationwide had not made significant progress in reducing errors over the past 10 years. It’s a question Dameron and the  commissioners have openly grappled with.
Speaking to the commissioners at Tuesday's board meeting, Higgins said,“I’m keenly aware that there’s somewhat of a sense of urgency that the commission grows and builds with the foundation that’s been set. Defining what success looks like is important. You need a way to measure the performance of the commission.”
By some of the commission’s own benchmarks and goals, it’s been falling behind.
A program for reporting serious adverse events in nursing homes has been stalled because, while most nursing homes participate, only 19 of 134 facilities (14 percent) submitted at least one report last year.
Only half of the state’s 82 ambulatory surgery centers are enrolled in a separate reporting program. 
When it comes to pharmacies, big-name chains such as Rite-Aid, Walgreens and Safeway still refuse to participate and that reporting program is stalled. Next to come are renal dialysis and birthing centers, but those programs have also been delayed. 
After four years of having hospitals report serious adverse events, the commission believes it’s probably only capturing about 10 percent of medical errors. 
Short of performing an in-depth review of medical errors over several years, there’s little way of knowing whether patient safety efforts are actually working.
On Tuesday, the commission reviewed a New England Journal of Medicine article about 10 hospitals in North Carolina, coincidentally where Dameron’s mother died eight years ago. The report looked at a sample of medical charts over five years and concluded the hospitals had not improved significantly in reducing serious errors.
“We’re kidding ourselves if we think we’re substantially different,” said Dr. Glenn Rodriguez, chief medical officer for Providence Health System who's a commission member. 
“Patient safety is still not part of the fabric,” said Norman Gruber, president of Salem Hospital. “It’s something you add in. Until we can change this culture, we’ll be fighting an uphill battle.”
For his efforts in taking on this monumental challenge, Dameron was honored with personal thanks and gratitude.
Dameron and his wife, Nancy Clarke, who retired last week as executive director of the Oregon Healthcare Quality Corporation, plan to take a Spanish immersion course in Central America and, when they return, spend more time in their cabin in the Wallowas.  

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By highlighting the dismal performance of the ten N. Carolina Hospitals, NEJM basically points to a National trend: Things have not improved on the Patient Safety front after the IOM report - After attending the IHI’s 22nd Annual Conference held in the first week of December, I strongly feel that major policy adjustments will have to be made to progress towards an error lees environment in the Healthcare Industry. We must seriously explore the possibility of learning and applying lessons from the High Reliability Organizations (HROs) such as airlines and nuclear. A solid commitment to Patient Safety is an absolute need of the hour! -- Dr. Tanveer Bokhari