Washington State has a law that requires hospitals to report “never
event” medical errors. The funny thing is, the hospitals aren’t
filing the reports. So, now the Washington State Department of Health
is investigating the reasons for this.
An investigation by Hearst Newspaper (chronicled in a
series of articles called Dead by Mistake) uncovered some possible reasons. One is that the medical error reporting
office is manned by one person. Yup, one person. One person to handle
reports by all the medical facilities in Washington State. Also, the office
is underfunded and lacked the money to hire a contractor to analyze the
reports. Further, there are no repercussions or penalties for failing
to file a report, even though it is mandatory.
Medical facilities in Washington have been required to report any of the
28 never events since 2006, yet just 52 percent of such facilities have
filed reports. According to
this article in the Seattle PI, the state should have received thousands of reports by now, but in fact
the Health Department has received about 550 as of July 2009.