Hospital Negligence - Reporting of “Adverse Events”
Stephen PokiniewskiJanuary 25, 2011 2:47 PM
Many people living in Pennsylvania would be surprised to learn that if they sustain an injury as a result of medical care while in a hospital or rehab facility the hospital or facility is required under the law to provide them with written notification of the “adverse event” and report the incident to a state agency.
In 2002, the Pennsylvania Legislature created the Patient Safety Authority (PSA) to reduce or eliminate medical errors by indentifying problems and recommending solutions to promote patient safety. As part of its mandate, the PSA developed a system for reporting “serious events” (involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in unanticipated injury requiring the delivery of additional healthcare services), as well as “incidents” (involving poor patient care, but not resulting in patient injury).
Health care facilities in Pennsylvania are required to notify patients or their families in writing when a serious event occurs. They must also advise in writing the PSA of the occurrence. The most recent annual report issued by the PSA indicated that there were 8,270 serious events and 218,400 incidents reported to the PSA in 2009. Unfortunately, the number of reported serious events and incidents has not decreased from the first year that these statistics started to be kept by the PSA. In 2005 the numbers were 7,504 adverse events and 161,568 incidents reported to the Authority. It should be noted that the starting in 2008 patients who develop a hospital acquired infection also are to receive an adverse event letter and the incident is to be reported to the PSA.
With the creation of the PSA and its notification requirements, my law firm has been consulted by a number of patients who have received adverse event letters from healthcare facilities. Two recent examples include wrong-sided surgery and the failure to notify a patient of the results of diagnostic testing, causing a delay in diagnosis and treatment. In both cases the patients ultimately died due to the adverse events. However, with a number of our clients no adverse event notification occurred despite the injury taking place in a health care facility.
While Pennsylvania law mandates written notification of serious events, the law does not require the facility to disclose any other information. It is our experience that often the notification letter is intentionally vague and does not clearly describe what took place in connection to the patient’s injury. It is my belief that this is done so that the health care facility includes as little information in writing as possible as to what specifically happened.
Receiving an adverse event letter is a very serious matter, as healthcare facilities only issue such a letter because they are required to under state law. The letter is not a legal admission of liability, but an acknowledgement by the healthcare facility of an injury (usually significant) to a patient. If you do receive such a letter, here’s what you can do: discuss with the hospital staff and your physicians what specifically occurred and how the resulting injury or injuries were or will be treated. You need to have a clear understanding of what occurred so that you can know how your health has been affected by the error and so that hopefully it will not be repeated.
The Pennsylvania law that created the PSA and the requirement of reporting “adverse events” and “incidents” is clearly a step in the right direction. Such authorities should be created in all states. This would greatly aid in determining the true nature and scope of errors taking place in the providing of medical care in the United States. Also, the fact that there were over 8000 reported instances where a patient was harmed by a medical error (serious event) in Pennsylvania in 2009 clearly indicates that there is a genuine problem with medical negligence in Pennsylvania health care facilities.