State Health Department Study Shows that Majority of New York Hospitals are Not Reporting Adverse Incidents

State Health Commissioner Calls for Increased Sanctions for Noncompliance

Albany, February 12, 2001– Ignoring statutory requirements, many hospitals in New York State are failing to report patient–related adverse events, including incidents involving medical errors, State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H. said today.

The New York State Health Department (the Department) released an analysis of 1999 data submitted through the New York Patient Occurrence and Tracking System (NYPORTS), the State's mandatory hospital incident reporting system. The report concludes that hospitals, particularly those in the New York City area, are significantly under–reporting adverse incidents. In one category analyzed through a comparative test (patient deaths within 48 hours of surgery) the statewide reporting compliance rate was only 16 percent.

"The Department is deeply concerned about the failure of hospitals to take their reporting obligations seriously and to comply with NYPORTS requirements that were developed, in full collaboration with the hospital industry, to identify adverse events, ensure necessary corrections and improve patient care," Dr. Novello said. "NYPORTS was implemented to be used as a tool for all New York hospitals to learn from the experiences of others. We did not implement this reporting system so that hospitals would ignore it."

New York State has required hospitals to report adverse incidents since1985. These include both unexpected bad outcomes and medical errors. The current system, NYPORTS, was created in partnership with hospital industry representatives, consumer advocates and representatives of medical specialities.

Dr. Novello said, "As I have said before, if a hospital has an adverse event and reports it promptly and accurately, then we will work with those hospitals to correct any problems and help them improve their services. For those hospitals that have ignored these critical reporting requirements, which are in place to help reduce medical errors and, in essence, help to save lives, we will identify you, single you out and sanction you in a public forum. Hospital noncompliance with these reporting requirements is unacceptable to this Department."

NYPORTS was phased–in over three years through a series of regional pilot projects. It was implemented statewide in 1998. Statistical information analyzed for this report represents the first full year of NYPORTS data.

Data analysis results:

The 1999 data analysis revealed large regional variations in the number of case reports submitted to NYPORTS per 100,000 patient discharges. Reporting frequency is three times greater in some parts of the State than others. New York City area hospitals had the lowest rate of reporting, with only 55 percent as many NYPORTS cases per 100,000 discharges as hospitals in the Hudson Valley–the next lowest reporting region. Finger Lakes, Central New York and Northeastern New York hospitals had the best reporting rates. Western New York and Long Island hospitals had rates similar to those in the Hudson Valley region.

Reporting variations per 100,000 discharges for the different regions of the state are as follows: Finger Lakes (1,101), Central New York (1,067), Northeast New York (986), Western New York (729), Hudson Valley (685), Long Island (711), New York City (377). New York City hospitals reported far fewer occurrences per 100,000 discharges, with only 55 percent as many as the next lowest reporter, the Hudson Valley. The average statewide average of reporting per 100,000 discharges was 625.

Variations in reporting frequency can result from factors including quality of care, the types of hospital admissions and procedures performed, and accuracy and completeness of reporting. The Department believes that the types of patient admissions and procedures performed should have only a minor impact on the variations because the size of the regions used to calculate the rates were large enough to offset those differences.

State officials don't believe that it's likely that there are significant discrepancies in quality of care from one region to another. Therefore, reporting accuracy and completeness is the most likely cause of the observed regional variations. The Department believes that the regional disparities are almost certainly attributable to under–reporting of patient events.

To further explore regional variations in reporting frequency, the Department used its Statewide Planning and Research Cooperative System (SPARCS) database to cross–check a specific NYPORTS data point: occurrence code 605, which specifies that a NYPORTS record must be supplied in the event of a patient death within 48 hours of an operating room procedure. After being adjusted to make them comparable, SPARCS data which describe patient deaths following surgery were matched against NYPORTS code 605 reports. A total of 1,030 cases was identified through SPARCS, but only 167 (16.2 percent) of the cases were reported through NYPORTS. SPARCS data contains a discharge summary for all patients admitted to New York State hospitals.

Benefits of NYPORTS:

Several examples show how NYPORTS can improve the quality of care in hospitals:

  • One hospital compared a list of its most common occurrence codes with those reported by other hospitals in the region. Another hospital's medical director noticed that his facility had a higher incidence of new Deep Vein Thromboses (DVT) than was the norm in his region, which was puzzling, since he had participated in development of a protocol to address that specific problem. After investigating, the medical director discovered that the (DVT) protocol had never been applied in his hospital and he was able to ensure that it was implemented, as planned.
  • At a regional meeting, local NYPORTS data were compared to statewide data, revealing that complications resulting from tonsillectomy/adenoidectomy surgery were higher in the region than elsewhere in the State. Post–operative bleeding was identified as a frequent complication of the surgery. Further case review turned up a critical link between excessive bleeding and the patients' post–surgical diet. As a result, the hospitals reinforced the importance of dietary restrictions to patient care staff.
  • Although instances of wrong–sided surgeries have been well–reported, a NYPORTS review of incorrect procedures or treatments shows that the problem extends beyond surgery to minimally–invasive procedures or treatments. For instance, insertion of chest tubes on the wrong side was identified in several cases, because medical staff failed to compare X–rays with previous studies or to reexamine the patient at bedside before placing the tube.

Dr. Novello said. "We are calling on all hospitals in New York State to demonstrate, with the State Health Department, a collective commitment to protecting patients. We have an important opportunity in New York State to reduce medical errors and improve patient outcomes, since we have an excellent reporting model already in place. I will not see that opportunity lost."

Next steps:

The State Health Department will undertake additional initiatives to address the issues uncovered as a result of the NYPORTS data analysis. These include:

  • The State Health Department will require all hospitals to go back and review their records for adverse incidents that should have been reported over the past two years (1999 and 2000). A report with those findings must be filed with the State Health Department within 60 days.
  • The State Health Department will seek legislative changes that would increase fines consistent with those applied for Resident Working hour limitations. Those hospitals found to be in noncompliance with NYPORTS requirements would be fined $6,000 for the first violation, $25,000 for recurrence and $50,000 if the problem is not corrected during a third inspection. The current maximum fine that can be imposed is $2,000 per violation.
  • Continuing to monitor reporting compliance through overall hospital surveillance activities and imposing sanctions for repeat failures to report as required. Hospitals that are sanctioned will be publicly identified.
  • Based on the finding of significant under–reporting of the 605 occurrence code, development of analysis to determine if under–reporting is a problem for other occurrence codes.
  • Encouraging collaboration among groups of hospitals to address specific types of patient occurrences in their regions, including identifying priority occurrence codes according to the frequency of occurrence and severity of patient outcomes and implementing appropriate follow–up.
  • Working to refine NYPORTS occurrence definitions and further facilitate the reporting process.
  • Providing additional training to hospitals on the proper use of NYPORTS and how to conduct a root cause analysis of medical errors and significant adverse outcomes.
  • Identifying the best ways to use NYPORTS data to improve quality of care in hospitals and sharing the information widely.

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2/12/01–14 OPA