Editorial: 20 years with 'no marked progress' in patient safety in Oregon

The commission is the state of Oregon’s organization that tries to keep patients safe from medical errors.

Patients die or get harmed because of medical errors. As careful as doctors, nurses, pharmacists and other medical professionals are, as well trained as they are, they are human. They make mistakes. There could be fewer.

Oregon’s Patient Safety Commission has a reporting program for hospitals, outpatient surgery centers, nursing facilities and pharmacies to report “adverse events.”

It reported 243 events in 2022. Falls were the most common event, followed by surgery mishaps, a delay in care, medication errors and on down the list. More than half the reported events resulted in serious harm or death of a patient. A communication error was the most common contributing factor.

That count of adverse events is likely incomplete. Participation in Oregon’s reporting program is voluntary by state law. All of Oregon’s hospitals and outpatient surgery centers do participate. In 2022, only 106 out of 130 nursing facilities did. Only 113 out of 659 pharmacies did.

Here is another sentence from that same draft annual report: “While many evidence-based practices for harm reduction have been identified, they are rarely shared beyond individual organizations or effectively implemented more broadly.”

Maybe Oregon should try something different if it wants more progress in patient safety.

Maybe if participation in Oregon’s reporting and resolution programs were mandatory rather than voluntary, things would be different.

But we don’t expect that to happen. Here’s to another 20 years without marked progress in patient safety in Oregon.