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Adverse Event Report: Why It Matters to Patients

Posted By Regan Zambri & Long || 7-Jun-2012

Posted by: Salvatore J. Zambri, founding member and partner

In its 2011 Annual Report, the District of Columbia Patient Safety Reporting Program summarized the process by which adverse event reporting and patient safety is reported as well as the results of the District of Columbia’s most recent reporting period. The purpose of the annual reporting is to comply with the District of Columbia Medial Malpractice Amendment Act of 2006. "The Act requires that any licensed healthcare provider or medical facility must report adverse events, which includes the 28 Serious Reportable Events defined by the National Quality Forum (NQF) as events that are unambiguous (identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.  In 2009, the Act was amended to require that adverse events reports must be reported within 60 days of their occurrence.  In January, 2010, a web-based adverse event reporting system was implemented in the ongoing effort to improve healthcare delivery."

For the 2011 report, the following highlights are noted:

  • "There was an increase in the number of NQF (National Quality Forum) and other events reports, not including HAI (healthcare-associated infections) events.  In 2010, 66 NQF and other events were reported and there were 90 in FY 2011.
  • A total of 112 adverse event reports were received.  Seven (6%) involved a patient death.
  • The majority of reports, 88 (78%), were submitted by acute care hospitals.
  • During the current reporting period there was an increase in the total number of event types reported, from 9 event types in FY 2010 up to 14 event types this past year."

The report states, "Medical errors and adverse events are a significant killer in the United States, and most are preventable."  Major categories of  medical errors listed were pressure ulcers, HAIs, falls, device related events, and surgical events.  The most frequently reported issue in almost every event was communication failure within a facility.  Other contributing factors include failure to follow protocol and failure to assess patients. Collecting and analyzing information about each incident is a first step in improving patient safety.  Using the information as an opportunity to improve the quality of medical care and education is the critical step to actually improve patient care.

"The District Patient Safety Reporting Program’s main goals include:

  • Promoting patient safety
  • Improving the culture of safety
  • Learning from and preventing adverse events
  • Providing feedback to District facilities."

Listed below are some of the previous posts that I have written about patient safety:

  • Medical Errors Should Be Reported to Improve Safety
  • Physicians Reluctant to Report Impaired and Incompetent Colleagues
  • Studies Show Interruptions Lead to Medical Errors
  • Evaluating a Medical Malpractice Case
  • Doctors Fail to Report Abnormal Test Rests At Alarming Rate
  • Nurse Interruptions, Distractions Lead to Medical Errors
  • Hospitals Failing to Protect Patients from Drug-Induced Bacteria
  • Studies Prove Poor Supervision of Resident Doctors Leads to Medical Errors
  • Are Hospitals Safe?
  • Medical Errors More Deadly Than Car and Truck Accidents Combined

As a practicing attorney for over twenty years, I have seen the results of preventable medical errors and the devastating effects they inflict on patients and their families.  Having an effective system in place that requires healthcare facilities to report on adverse events is a beginning to prevention of those types of errors and improving patient safety.  Much more needs to be done beyond the reporting of events to actually impact patient safety, namely, action. 

Do you have any questions about this post?

About the author:

Mr. Zambri is a Board-Certified Civil Trial Attorney and Past-President of the Trial Lawyers Association of Metropolitan Washington, D.C. The association has recently named him the " 2011 Trial Lawyer of the Year".  He has also been acknowledged by Washingtonian magazine as a "Big Gun" and among the "top 1%" of all of the more than 80,000 lawyers in the Washington metropolitan area. The magazine also acknowledged him as "one of Washington’s best–most honest and effective lawyers" who specializes in medical malpractice matters, product liability claims, and serious automobile accident claims. Mr. Zambri was recently (2011 edition) acknowledged as one of the "Best Lawyers in America" by Best Lawyers, and has also been repeatedly named a "Super Lawyer" by Law and Politics magazine (2011)–a national publication that honors the top lawyers in the country.

Mr. Zambri is regularly asked to present seminars to lawyers and doctors, as well as both medical and law students concerning defective drugs, medication errors, medical malpractice litigation, and safety improvements.

If you have any questions about your legal rights, please email Mr. Zambri at szambri@reganfirm.com.  You may also reach him at 202-822-1899.

 

 

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