States target serious medical errors that never should happen

Hospitals and physicians hope these new laws will help improve patient safety, while not giving plaintiffs' lawyers another hammer.

By Kevin B. O'Reilly, AMNews staff. Jan. 2/9, 2006.

Late last year, Illinois became the fifth state to enact a law or rule requiring hospitals to publicly report so-called never events -- serious errors that patient safety experts say never should occur, for example, wrong-site surgery.

With several more states examining the idea, it appears the never-events approach to improving patient safety could supplant the broader medical-error reporting laws already on the books in 27 states.

Experts say the new laws are more focused and prevent discoverability in litigation, and thus will make it easier for hospitals to share patient safety strategies with each other.

The older laws generally require hospitals to report a much wider range of medical errors and don't specifically shield safety discussions from being discovered, according to the Health Policy Tracking Service, started by the National Conference of State Legislatures but now owned by an independent publishing firm.

"The broader statewide reporting initiatives have been a waste of time and money," said Robert Wachter, MD, editor of the patient safety journal AHRQ Web M&M. "Every hospital in the United States, even the best, has hundreds of errors each month, and there is no value to accumulating hundreds of thousands of reports in some bureaucracy. The key thing is: How do reports generate action?"

The new Illinois law, like the Minnesota, Connecticut, Indiana and New Jersey measures that preceded it, has at its core a set of National Quality Forum-endorsed consensus standards developed by groups representing physicians, researchers, health insurers, employers, workers and consumers. The Illinois legislation covers 24 of the 27 NQF standards.