Date: 08/11/2009
Final
Patient Safety
HEALTH CARE TASK FORCE
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02:36 PM -- Patient Safety
Dr. David West, Colorado Patient Safety Coalition, introduced his organization and described its mission to foster a culture of patient safety. His organization has more than a thousand participants, including patients, hospitals, medical liability managers, and others. He described the Colorado Patient Safety Organization as an independent broker of information that brings the different groups together to discuss and improve safety. He shared a document with the committee on medical errors and resulting deaths and costs (Attachment K). Dr. West said that the public is concerned with patient safety and that many individuals have experiences regarding medical errors. He described organizing a leadership task force to reduce medical errors and increase patient safety. Dr. West described his organization's agenda as embedding patient safety in health care culture, coordinating health care when transitioning between care settings, and fostering the creation of a patient safety organization.
Donna Kusuda, Rocky Mountain Patient Safety Organization (PSO), described her role with the PSO and the Colorado Hospital Association (CHA). She provided handouts to the committee concerning the PSO and the CHA's safety initiatives (Attachment L). She discussed the CHA's initiatives such as the hospital safety report card, color coding hospital wrist bands, standardizing emergency room hospital codes, and implementing the World Health Organization surgical checklist. She also described the CHA board's role in forming the Rocky Mountain Patient Safety Organization. She gave background information on federal law concerning the reporting of adverse events and the creation of patient safety organizations. She described the process of sharing and analyzing information within a PSO and medical liability concerns, and discussed how previously providers could not share information on adverse events out of concern for liability. She stated that providers can now participate and share information freely to promote best practice and safety improvements. She described the process for reporting incidents to the PSO and analyzing the data. She said that most PSOs focus on hospital providers, but she said her goal is to include all types of providers, and that the focus on patient safety should include all types of care settings. She discussed regional efforts to include other states in the initiative in order to get more complete data. She discussed how patient safety organizations can benefit patients, providers, and medical liability companies, and promote collaboration and improved safety.
03:00 PM
Representative McCann thanked Ms. Kusuda and asked about the PSO's goals in analyzing data. Ms. Kusuda described how data can be analyzed to provide conclusions and guidance to providers. Senator Schwartz asked about protections from discovery and disclosures. Ms. Kusuda said that there are rules about how information can be shared in order to maintain confidentiality and that there is some data that can be released publicly. Senator Foster asked about the level of detail shared about providers who report incidents. Ms. Kusuda said that information on the providers who commit errors can be shared with their permission. Senator Foster asked why it is in the provider's interest to share information on adverse events with the PSO. Ms. Kusuda said that many providers want the analysis, and to know what trends exist among providers. Senator Foster asked what the PSO's responsibility was to the public for facilities that have poor records of safety. Ms. Kusuda said that the PSO is a provider service organization and that her duty is to tell the provider that their record is outside the norm.
03:08 PM
Judy Ham, United Cerebral Palsy of Colorado, began her presentation on birth injuries. A handout was distributed to the committee (Attachment M). She said that when an adverse incident takes place, it is a very upsetting event and that the medical liability system does not always provide recourse. She said that compensation through the medical liability system is unpredictable and inequitable, and that the medical liability system does not always promote safety improvements since many medical errors are not even reported. Ms. Ham discussed a pilot project for compensation and liability that her organization is developing. Senator Boyd asked if a large portion of malpractice claims are from birth injury cases. Ms. Ham said that claims only result from a small portion of errors and that not all incidents are the result of negligence. She stated that it is difficult to assign fault in some situations and that there is a need to gather data to better understand the issue. Dr. West said that birth is an emotional time and that if something seems to go wrong it can result in a claim. Senator Schwartz said that there are many costs that result from extra tests done due to liability concerns and asked if there could be some way to reduce these costs. Ms. Ham said that her focus is on helping the child and trying to improve the outcomes for the child. Dr. West said that about $17 billion a year could be saved from preventable medical errors, in addition to the emotional costs, and that the biggest cost is from follow-up care after an error rather than from extra testing. Representative McCann asked about health courts. Ms. Ham said that they haven't really talked about health courts when planning their pilot program and that they are focusing on getting compensation and accountability.
