CHEYENNE - Wyoming health care facilities reported 43 accidents and errors last year, two of them resulting in deaths, according to a Wyoming Department of Health analysis that casts doubt on the thoroughness of reporting in the state.
The department's third annual report on "adverse health events" covers July 2007 through June 2008. The total of such events remained unchanged from fiscal year 2007 and was down from 58 in fiscal year 2006.
"It really is hard to make any assumptions from the report because the numbers are small," Health Department Director Dr. Brent Sherard said. "We're finding that a lot of health care facilities are not reporting."
But Sherard said he doesn't believe the possible underreporting indicates that patients are worse off in Wyoming than in other states. "My gut feeling is that our patient safety errors are probably very similar to what's experienced across the rest of the country," he said.
The Legislature in 2005 mandated that all health care facilities - from hospitals to dialysis centers and nursing homes - report their mistakes and errors to the health department. Reportable events range from surgical errors to equipment malfunctions, medication errors, electric shocks and criminal events occurring in a facility.
Sixteen of the state's 200 health care facilities reported errors or accidents in fiscal year 2008. The reports included 25 injuries associated with a fall, two deaths resulting from falls, 11 medication errors, three cases of serious bed sores and two patients sexually assaulted. It also found there were two surgeries that resulted in foreign objects accidentally left in a body.
The 2005 law mandated that the details of events remain confidential, that facilities not identify specific people involved, and that the reports not be discoverable in a lawsuit. The health department records which facilities the events occurred at, but department employees declined to release information on the locations of specific events.
"The idea was to get some basic data to see what's going on and see if further legislation needs to be brought forth or a bigger program needed to be brought forth," said Clay Van Houten, the health department's emerging diseases/health statistics section chief. "I think as part of that, they felt that to get good reporting, if you basically made it anonymous, aggregated data, it would increase the number of reports coming in."
Other states have more liberal policies for sharing the results of their patient safety reporting. For instance, the Colorado Department of Public Health and Environment produces an annual report card detailing what occurred at each of the state's hospitals.
Sherard said the goal of Wyoming's system is to improve patient safety in health care facilities in the state, and he doesn't believe that identifying specific institutions would help.
He said there are enough problems in health care without "fingerpointing at institutions and providers."
"I think every institution and every provider out there has made a mistake at one time or another," Sherard said. "But what I think we need to do is identify those problems that are significantly seen and try to provide proper training, education and resources that can be utilized to mitigate and eliminate many of these problems."
Sherard and others in Wyoming's health industry say it's possible that the state's health care facilities are reluctant to report mistakes or errors because they're not convinced that the 2005 law is strong enough to keep their reports from being used against them in lawsuits.
Dan Perdue, president of the Wyoming Hospital Association, said he doesn't know whether the health department is correct to presume that Wyoming health care facilities are underreporting their accidents and errors.
"One thing that is not brought out in any of (the health department's) conclusions is the fact that in some cases a hospital may not report for fear of this being accessible in the public domain by a plaintiff's attorney," he said.
In an effort to alleviate that concern and provide a forum for health care facilities to discuss their errors, the Wyoming Healthcare Commission has been leading an effort to form a "patient safety organization" in the state.
In 2005, Congress passed a law allowing the formation of patient safety organizations - groups where facilities can voluntarily discuss their errors and develop ways to reduce patient risk in a privileged and confidential environment.
Executive Director Susie Scott said the Wyoming Healthcare Commission has been studying the formation of a patient safety organization with the help of interested parties like lawyers, insurers, physicians and the hospital association.
"It would be a voluntary organization made up of hospitals and clinics and health care providers throughout Wyoming with a keen interest in patient safety, preventative measures and having more effective ways to prevent what we call near-misses," she said.