'Never events' at hospitals go unnoticed

Sarah Okeson | News-Leader.com | October 29, 2011

...Gillham's suicide at the the Cox North psychiatric facility is what the health care profession sometimes calls a "never event," tragedies that are not supposed to happen in a health care setting. Such events also include surgery performed on the wrong patient or a woman dying in labor during a low-risk pregnancy. Hospital patients and their relatives in Missouri and most of the United States have no way of learning about most adverse events. A federal website lists the rates at hospitals for some patient safety data such as accidental cuts and tears from medical treatment, but most adverse events aren't publicly reported.

In Minnesota, the state publicly reports adverse events by hospital online. Illinois plans to publicly report adverse events by hospital. They're part of a small but growing number of states trying to bring more transparency to hospitals and to the bad things that can happen in them. Under a 2005 federal law called the Patient Safety and Quality Improvement Act, hospitals can report errors or other problems to patient safety organizations, but the reports are confidential. The reports aren't subject to subpoenas, records requests from disciplinary proceedings or requests from the media.

"Basically, they're swept under a rug," said D.K. Raymer, who founded a small patient advocacy organization in Springfield called HealthCare PSI.