New York State Department of Health - NYPORTS
The New York Patient Occurrence
Reporting and Tracking System
Annual Report 2000/2001
Governor George E. Pataki and Antonia C. Novello, M.D., M.P.H., Dr. P.H., Commissioner of Health, have affirmed that the most important responsibility of the Department and the healthcare community is to assure the highest quality of care to patients in the safest possible manner. Recently, Commissioner Novello stated, "Together we will continue to strengthen New York's health care system by enhancing safeguards and protocols to ensure patient safety."
In keeping with the goal of providing quality, safe healthcare, the Department of Health developed the New York Patient Occurrence Reporting and Tracking System (NYPORTS). For the purpose of NYPORTS reporting, an occurrence is an unintended adverse and undesirable development in an individual patient's condition. Since the issuance of the Institute of Medicine's (IOM) Report, To Err is Human, in late 1999, national attention has been focused on medical errors. All adverse events are not medical errors and should not be considered as such. NYPORTS does collect reports on medical errors, but the volume of medical errors in the system is a small percentage compared to the overall volume of reporting. The data that is collected in NYPORTS is a tool that facilities may use to assist in internal quality initiatives and medical error prevention.
In this second report on NYPORTS, the Department will provide a compilation of information from the years 2000 and 2001. The report will present information detailing system upgrades, reporting compliance, data analysis of adverse events, future plans, and Department initiatives associated with NYPORTS.
To achieve the goal of improving patient safety, the Department believes that there must be an awareness and recognition of adverse events by facilities. In support of increasing reporting compliance, Commissioner Novello notified hospitals in February 2000 that, while the Department is ready to assist hospitals in meeting statutory reporting requirements, it also "stands ready to enforce requirements, and will publicly sanction those facilities that fail to promptly and accurately report incidents." The Commissioner also directed hospitals in a February 2001 letter to conduct internal reviews to identify any unreported events occurring in 1999 and 2000 and to report them to the Department within 60 days. In response, a significant increase in reporting was noted. Reporting has remained at that elevated level.
Although reporting has risen to a higher level in 2000 and 2001 in response to Commissioner Novello's directive, there are still improvements to be made. Complete reporting is crucial to utilizing NYPORTS data as a tool for quality improvement and adverse event reduction efforts. Although reporting in 2000 and 2001 shows improvement, it is clear that there are still a large number of cases that remain unreported. The monitoring of incident reporting will continue to be a high priority for the Department of Health. It is the intention of the Department to assist facilities in not only meeting their mandatory reporting requirements, but also to exceed the current level of reporting in future years.
Under the direction of Governor George E. Pataki and Department of Health Commissioner Antonia Novello, M.D., M.P.H., Dr. P.H., a panel was convened in May of 2000 to address serious patient care concerns raised as part of Department of Health surveillance activities. In keeping with the commitment of reducing medical and surgical errors, the panel endeavored to develop a guideline for hospitals and other providers, to ensure quality operative care. Panel members sought to identify definitive practices for ensuring safe patient care outcomes and avoiding surgical errors. The result was the development of the "Pre-Operative Protocols", a list of recommendations designed to reduce the occurrence of wrong side or wrong patient surgeries. These protocols were issued in February of 2001 to all hospitals, and are considered applicable across a variety of health care settings, such as ambulatory surgery and interventional radiology. Facilities are expected to implement these protocols as a baseline, and to expand upon them to make them appropriate for their settings. There is also evidence to suggest the benefit of expanding pre-operative protocols to address specific areas of the system, such as communication. The Department of Health is confident that the use of these protocols will result in a reduction of these types of clearly preventable surgical errors.
As stated above, reporting improved during the year 2000 and 2001. The following is a list of significant improvements:
- The number of reports submitted to NYPORTS increased from 16,939 cases in 1999, to 24,368 in 2000, and to 28,689 in 2001.
- Reporting has increased from 716 reports per 100,000 discharges in 1999, to 1,004 reports per 100,000 discharges in 2000, to 1,159 reports per 100,000 discharges in 2001.
- NYPORTS reporting per 100,000 discharges has risen 61.9% from 1999 to 2001.
- With the exception of one region, all geographical regions in New York State noted increases in reporting in 2000 and 2001, as compared with 1999. From 1999 to 2001, improvements ranged from an 18.4% increase in the Central New York region to a 109.2% increase in the New York City Region. In 2000 and 2001, the Northeast region had the highest reporting rates, while the New York City Region had the lowest reporting rates. In 2001, Central New York had a 3.4% decrease in reporting as compared with 2000.
- For the code 605 (Death occurring after procedure) events, the reporting percentage increased from 16.2% in 1999 to 80% in 2000, and remained at a high level, 73%, in 2001.
- Data provided in this report demonstrates that regional variations with reporting, though still evident, are diminishing.