Partners in patient safety.

Byline: The Register-Guard

Numerous promising strategies could help reduce the staggering number of patients - as many as 98,000 by some estimates - who die annually in the United States from preventable medical errors. But their success ultimately depends on an honest, accurate and consistent system for reporting "adverse events," as such errors are known in the medical profession.

Conventional wisdom says that a medical error reporting system needs a hammer - typically a state law making error reporting mandatory and prescribing sanctions for medical facilities that fail to comply. But Oregon often bucks conventional wisdom.

Oregon's innovative approach to tracking adverse events involves a small state organization called the Patient Safety Commission. Created by the Legislature in 2003, the commission is responsible for developing and maintaining an adverse event reporting system. The unconventional part: The system is confidential, completely voluntary and nonpunitive.

Balanced against the risk that some hospitals might withhold or underreport serious errors is the potential for meaningful statewide collaboration on successful strategies to reduce and prevent mistakes. Right now, the commission has more reason to be optimistic about the potential than to be concerned about the risks.

In its most recent analysis, the Patient Safety Commission reported that 24 patients died in Oregon of preventable errors in 2007, compared with 21 in 2006. The report included data from 54 of the state's 57 acute care hospitals, representing 99 percent of the hospital care provided in Oregon. That's an impressive participation rate, bolstered this year by the addition of the 55th hospital.

Five kinds of adverse events account for 60 percent of the reports: retained objects (19 percent), which refers to objects, such as sponges, unintentionally left in a patient after surgery; wrong site procedures (10 percent), which covers incisions or anesthesia in the wrong location; medication errors (10 percent); falls (9.5 percent); and infections (9 percent).

The disproportionate number of retained object errors led the commission to convene an expert panel to develop recommendations. Using best-practice information from around the nation, the panel created guidelines aimed at reducing the potential for retained object errors. The recommendations were adopted by the commission and shared with all hospitals in the state. An added benefit is that the recommendations promote and enhance general safe surgery practices.

Interestingly, there is a common factor that is cited as a fundamental cause in a majority of medical errors: poor communication. Improved communication may be one of the most effective of all strategies to reduce errors.

Despite its low profile, Oregon's Patient Safety Commission is one of the most important contributors to health care improvement in the state. But it can be successful only if the participating hospitals are forthright about reporting errors. All Oregonians benefit when the hospitals and the commission are full partners in patient safety.