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Maine Hospitals Not Reporting Serious Harms to Patients, Study Finds

1296420_81434190.jpgReports from both the federal and state governments show that hospitals may be under-reporting serious adverse events, known in Maine as “sentinel events,” to government agencies, despite statutes in many states requiring such reporting. Maine enacted a statute, which took effect in May 2003, requiring hospitals and other medical facilities to report such events to the state Department of Health and Human Services (DHHS). The statute defines sentinel events as those involving a patient’s unexpected death or permanent incapacitation, serious medication errors, or criminal acts involving or against a patient. DHHS officials have found that the number of sentinel events reported by Maine medical facilities is lower than the expected number based on national surveys.

Maine’s Mandatory Sentinel Event Reporting Statute applies to hospitals, outpatient surgical centers, end-stage renal disease facilities (ESRDs), and treatment centers for patients with mental retardation. The statute requires these facilities to report sentinel events to the DHHS’ Division of Licensing and Regulatory Services within twenty-four hours of the event or face fines. The facility has forty-five days, once the DHHS finishes its review, to identify the cause of the error and develop a plan for remedying any deficiencies and preventing future errors.

The DHHS’ report for calendar year 2011, issued in June 2012, identifies ten types of sentinel events:

Hemolytic transfusion reactions, adverse reactions by a patient’s immune system after a blood transfusion;
– Major losses of function, such as paralysis or organ failure unrelated to the ordinary course of the patient’s condition;
– Sexual assault of a patient;
– Suicide or attempted suicide by a patient;
– Unanticipated death of an otherwise healthy patient;
– Unanticipated transfer of a patient to another facility that harms the patient’s condition;
– Wrong-site surgery;
– Falls or other physical injuries;
– Pressure ulcers, commonly known as bedsores;
– Retained foreign objects.

Maine has also largely adopted the National Quality Forum’s (NQF) list of Serious Reportable Events. The NQF is a nonprofit group that advocates for standardized healthcare quality. Its list of events is becoming standard for states that are enacting mandatory reporting laws.

THe DHHS report identified 163 reported events during 2011, but the official who monitors the program reportedly thinks the number may be as high as 300 to 400. Unanticipated death was the most prevalent, accounting for sixty-one of the events. Falls and other injuries, major losses of function, and bedsores each accounted for more than twenty events. Thirty-seven hospitals, or ninety percent of the hospitals obligated by law to report sentinel events, gave reports during 2011. One hundred percent reported in 2010, but there is still a positive trend from previous years. In 2007, for example, only seventy-eight percent reported.

The public and other healthcare facilities do not have access to event reports, so no statistics are available on events at specific facilities. The reporting system is therefore not very helpful in a claim for damages from a sentinel event. State officials have suggested that fear of liability or blame could lead to fewer reports from hospitals, but others suggest that some hospitals do not recognize events as reportable.

At Briggs & Wholey, we represent the rights of people in Maine who have suffered injury or lost loved ones as a result of medical malpractice. To schedule a free and confidential consultation to discuss your case, contact us today online or call (888) 596-1099.

Web Resources:

Sentinel Events: Annual Report to the Maine State Legislature, CY 2011 (PDF), Department of Health and Human Services, June 2012 (source)

More Blog Posts:

Wrongful Death: Misplaced Feeding Tubes Kill Maine Patients, Maine Personal Injury Lawyers Blog, April 5, 2009
A Second Opinion for Maine Patients: Is Malpractice Linked? Maine Personal Injury Lawyers Blog, January 5, 2009
Childhood Ear Infections and Cholesteatoma, Maine Personal Injury Lawyers Blog, May 29, 2008
Photo credit: ‘bacteria 1’ by gerard79 on stock.xchng.