State medical mistake reporting system too vague, says senator


by MEG COYLE / KING 5 News

Bio | Email | Follow: @MegCoyleKING

Posted on October 4, 2010 at 6:12 PM

Updated Monday, Oct 4 at 6:13 PM

SEATTLE – Washington state's medical error reporting policy is under the microscope after three recent mistakes at Seattle Children's hospital, resulting in the deaths of two children.

State Senator Karen Keiser, D-Kent, plans to introduce legislation to beef up the state's current program when it comes to reporting medical errors. Under the current system, Keiser says the rules are too vague and the public uninformed.

On a chart in tiny print on the state Department of Health's website is a list of hospitals and the mistakes they've made. That's where the information stops. There are no specifics on who's committing the errors or why.

UW medical bioethicist Dr. Tom Gallagher co-authored a study on the need to disclose all medical errors in order to protect patient safety.

"There's this enormous potential to learn from these mistakes and at the moment we simply don't have the systems in place to allow that to happen," he said.

Take 15-year-old Michael Blankenship. He died after having dental work at Children's. He was autistic and couldn't swallow pills. The dentist prescribed a pain patch containing fentanyl. Michael died the next morning from a fentanyl overdose.

"The public deserves to know when something like this happens," says Dr. Gallagher.

And then there's the question of what is considered a medical error. Last week, we showed you the heartbreaking story of two-year-old Osman Ali. He underwent a procedure at Seattle Children's for a heart defect, but it left him unable to do anything but breathe.

Children's never reported it. It didn't have to under the current state guidelines.

But Gallagher believes the more transparent the hospital, the more trusting the patient.

"They get meaningful information back on the lessons learned and how to prevent recurrences," he said.

Sen. Keiser says one way to support the funding arm of the state's disclosure program is by assessing hospitals to help shoulder the cost.  Right now, the state can't afford to run the program the way it's intended.  She is also considering penalties for hospitals that fail to report.