• California patient safety changes slow in coming, despite 13,500 deaths each year Thursday, March 18, 2010

    What’s taking the California Department of Public Health (CDPH) so long to implement a program to prevent hospital acquired infections?  That’s what Consumers Union has been trying to find out since December, but the watchdog group isn’t getting answers.

    CU’s Safe Patient Project has released a report that says CDPH “has been slow to implement many of the key provisions” of six patient safety laws that have been passed by the California Legislature since 2006.  Those laws were passed because lives are at stake.  According to CDPH, 13,500 people die each year in California’s acute hospitals as a result of healthcare associated infections, defined as “infections that occur during or as a consequence of the provision of healthcare.”

    Safe Patient ProjectThe same CDPH report says there are 240,000 healthcare associated infections in California each year, accounting for more than $3 billion a year in excess health care costs.  (Note these numbers refer only to infections, not to costs or deaths resulting from any other type of medical error or negligence.)

    But Consumers Union says “it appears that [CDPH] has failed to carry out important provisions of recent patient safety laws.”  Here are some of the organization’s specific complaints:

    1) The department was required to establish a surveillance and prevention program for hospital acquired infections by January 2008 but didn’t begin to do so until 20 months later.

    2) The department still doesn’t publish reports detailing each hospital’s record of compliance with Centers for Disease Control and Prevention guidelines to prevent central line and surgical site infections and to vaccinate healthcare workers and patients for influenza.  That was also supposed to happen by January 2008.

    3) CU says it is “unclear” what steps the department has taken to ensure hospitals are complying with requirements that aim to reduce the incidence of MRSA infections.

    4) The department has not revised existing hospital infection regulations or adopted new ones to incorporate current CDC guidelines for preventing infections.

    5) Beginning in July 2007, hospitals were required to report certain medical errors to the state, and CPH was supposed to make information about the incidents readily accessible to Californians.  But CU says the department “only discloses detailed information to the public about medical errors when hospitals are fined.  When fines are not imposed, the department discloses only minimal information about reported adverse events to the public.  Information about reported medical errors is difficult to find on the department’s web site.”

    6) It’s “unknown” whether the department has begun conducting required unannounced hospital inspections to determine compliance with medical error prevention policies.  Likewise, it’s unknown whether CDPH is taking steps to ensure hospitals are informing patients or their caregivers after medical errors occur, as required.

    “Consumers deserve to know how well hospitals prevent errors and infections,” according to the report.  “They deserve to be assured that the government is fulfilling its role of protecting the public.”

    At HealthyCal.org, Daniel Weintraub explained why the report was issued:

    Consumers Union has been working behind the scenes with the Department of Public Health for months to try to determine the status of the state’s compliance with laws on reporting and disclosure of infections and errors.  But when the group concluded that the department was stonewalling, Consumers Union filed a public records request to try to get the data.  When the department failed to respond to that request in a timely way, the group decided to go public with its complaints.

    CDPH spokesman Michael Sicilia e-mailed a statement to Weintraub in which he said, “CDPH believes it has adhered to all legislative deadlines for compliance and reporting of medical adverse events.”  When we asked Silicia for additional comment, he said, “At CDPH, our first priority is to protect the health and safety of all Californians.  We strive to do so in a manner that is transparent and open.”

    Consumers Union acknowledges CDPH has begun assessing fines to hospitals that report adverse events and posting that information online.  A story in the Los Angeles Times earlier this week detailed one of those events that happened at Parkview Community Hospital in Riverside in July 2009.  Francisco Torres had a tumor on one of his kidneys and went into surgery to have the kidney removed.  But the surgeon, who did not have hospital privileges to perform kidney surgery, removed the wrong kidney, and Torres is now on dialysis.

    Molly Hennessy-Fiske described how the situation was handled:

    Parkview Community Hospital reported the Torres kidney error to the state the day after his surgery, state records show.  Investigators visited the hospital, interviewed staff and found the hospital had erred….Torres, a Mexican immigrant who does not speak or read English, had not had his condition or the surgical consent forms explained to him by hospital staff in Spanish, so he could not have known that the wrong kidney had been marked for removal, investigators wrote.

    The hospital submitted a plan of correction to regulators in January noting that it had improved translation services, verification that surgery is performed on the correct body part and monitoring of surgeons’ credentials.

    According to CDPH’s Center for Health Care Quality, which has regulatory oversight of health facilities, 90 hospitals in the state have been fined for preventable errors.

    –J.G. Preston

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