PORTLAND, Ore. — The Oregon Patient Safety Commission has released a report summarizing the data gathered by Oregon’s Patient Safety Reporting Program in 2014. Last year, the program received a total of 624 reports about unintended harm to patients as a result of medical care (also called “adverse events”). Reports are submitted by participating hospitals, nursing facilities, ambulatory surgery centers, and community pharmacies.
An analysis of adverse event data from all four healthcare segments found that, similar to years past, Fall, Medication or other substance, Surgical or other invasive procedure, and Care delay events were the most frequently reported adverse events. As expected from the program’s emphasis on serious adverse events, almost half of the reports submitted to the Commission in 2014 (45%) resulted in serious harm or death. The types of adverse events and the severity of harm reported by each healthcare segment varies based on the services offered, the patient population served, and the processes and systems in place to support quality improvement and patient safety.
“We believe that continued, sustained reporting can be attributed to the maturity of the program and an ongoing dedication to transparency and improvement on the part of participating healthcare facilities,” says Bethany Walmsley, Commission Executive Director. “Reporting program participants are seeing the value of working together to share important lessons. By sharing, all healthcare organizations in Oregon have an equal opportunity to learn and implement the improvements that lead to a strong culture of safety and protect their patients.”
The Commission continues to provide reporting program participants with hands-on support to ensure that Oregon has a robust, statewide pool of information that can be used to identify themes and facilitate shared learning. The Commission provides ongoing technology enhancements and in-person trainings to help healthcare facilities improve their adverse event investigations and develop the system-level action plans that can help prevent harm to patients in the future.
The report, 2014 Annual Summary: Oregon Patient Safety Reporting Program, is available at: http://oregonpatientsafety.org/reporting-programs/annual-summaries/
About The Oregon Patient Safety Commission
The Oregon Patient Safety Commission is a semi-independent state agency charged by the Oregon Legislature with reducing the risk of serious adverse events occurring in Oregon’s healthcare system and encouraging a culture of patient safety. The Commission offers a variety of patient safety programs including the Patient Safety Reporting Program, Early Discussion and Resolution, and various quality improvement collaboratives. Visit our website for more information.
