State Health Commissioner Novello, Comptroller Announce Changes in System Tracking Accidental Deaths, Injuries in Hospitals & Clinics

Reforms Aimed at Improving Comprehensiveness, Accuracy, Timeliness of Reporting

Albany, September 28, 2004 - New York State Department of Health (DOH) Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H., and State Comptroller Alan G. Hevesi today announced changes in the State's system for tracking accidental deaths, injuries and other adverse medical incidents at hospitals and other health care facilities. The reforms will improve the comprehensiveness, accuracy and timeliness of information reported to the state, helping to guide DOH's surveillance and health care facilities' quality of care decisions in a collective effort to further prevent adverse medical incidents.

The announcement was made as the Office of the State Comptroller (OSC) released an audit of DOH's database of critical incidents at health care facilities around the State, known as the New York State Patient Occurrence Reporting and Tracking System (NYPORTS). The Reporting System, which has achieved national recognition and provided a model for other States, was created in 1998 and continues to be improved.

Dr. Novello said, "New York's hospitals and health clinics have steadily increased their reporting of adverse patient incidents to the State in recent years, thereby assuring greater quality assurance oversight and quality health care for patients. I commend the leadership efforts of Governor Pataki to further protect the health and well-being of New Yorkers. We can always do more and our coordination with the State Comptroller's Office on this critical issue will help further strengthen New York's world-class health care system into the future."

"New Yorkers look to DOH to ensure that hospitals and other health care facilities are operated safely and lawfully, and NYPORTS is an important tool for us to address the public's concerns," Comptroller Hevesi said. "NYPORTS data is critical for DOH and individual facilities to help them make quality of care decisions, and to address and prevent medical incidents. Without accurate and complete information, it is not possible to effectively pinpoint and address problems. That is why I am pleased that DOH chose to respond immediately to our audit and make needed changes."

The changes in NYPORTS include tighter and more carefully monitored timelines for reporting incidents and analyses of their causes, and increased potential for sanctions against facilities that submit late or incomplete reports. Using criteria described in Department guidelines, the audit found that 84 percent of 5,777 deaths and other serious medical incidents reviewed were reported more than 24 hours after the occurrence. While reporting requirements do provide hospitals with additional time to determine if an event is reportable, there were delays in making these determinations. With regard to less serious patient incidents, which must be reported within 30 days, auditors found 89 percent (1,032 out of 1,166) of such occurrences were reported on time.

Clarification has been issued to facilities to report serious occurrences within 24 hours or one business day of when the incident occurred or when the hospital had reasonable cause to believe that such an incident had occurred. Changes are being made to NYPORTS that will allow the facility to enter both the date of occurrence and the date of determination that event was reportable.

NYPORTS includes data from 263 hospitals and 1,350 clinics around the State. An occurrence is defined as an adverse and undesirable development in an individual patient's condition that was not caused by the natural course of illness, disease or proper treatment. Unexpected patient deaths and equipment malfunctions that result in patient harm are classified as most serious occurrences in NYPORTS. Less serious occurrences include patient falls resulting in fractures or second- and third-degree burns.

OSC auditors noted that DOH officials had taken action in recent years to improve NYPORTS reporting. In fact, DOH reported that total incidents reported increased by 62 percent from 1999 to 2001.

Medical facilities are required to investigate all of the most serious occurrences, and to submit a report within 30 days to DOH and enter it on NYPORTS, although extensions can be granted. Auditors found that 11 percent of the investigation reports (264 out of 2,505) during the audit period had not been submitted, with nearly half of the late reports overdue by more than one year.

OSC auditors looked at the period January 1, 2001 through May 21, 2003, during which a total of 65,822 occurrences were reported on NYPORTS.

A hospital or clinic that fails to comply with reporting requirements can be fined as much as $2,000 per violation. DOH also issues citations for noncompliance, which do not carry a fine but require facilities to submit a written corrective action plan. However, auditors determined that DOH did not have formal criteria to determine when hospitals and clinics should be fined or cited for failure to report incidents, and that different DOH field offices around the State responded differently to reporting violations. Auditors found that, during the 29-month period covered in the audit, only two facilities were fined and only 20 citations were issued.

Hospitals enter information directly into the NYPORTS system through a statewide computer network. Clinics do not have access to this network, so they report information to DOH field offices where it is then entered into NYPORTS. Auditors reported that DOH officials at field offices in Buffalo, the Hudson Valley and Long Island stated that they do not enter clinic information into NYPORTS because they do not have adequate staff or because NYPORTS has not been programmed to include data on certain clinics.

Soon after the draft audit was presented to the Department of Health, guidelines were clarified and a communication plan was implemented to inform hospitals, clinics, DOH central office and regional staff of the audit findings and plans to address problems that were identified. Specific changes in NYPORTS reflect recommendations outlined in the OSC audit including: expanding DOH efforts to identify unreported occurrences to enable more systematic analysis of the data; developing written guidelines for enforcement of all NYPORTS reporting requirements so they more effectively reflect DOH expectations and will be the same throughout the State; and creating a system to identify medical facilities that consistently fail to report occurrences on time.

Comptroller Hevesi noted that OSC will conduct a follow-up audit to assess the effectiveness of the new NYPORTS policies and procedures once they have been implemented.

Office of State Comptroller
Press Contact:
Dan Weiller (518) 474-4015