Quality & Patient Safety

California posts adverse event data

Patient Safety Monitor Alert, July 9, 2008

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During a 10-month period beginning in July 2007, 466 patients in California developed pressure ulcers so severe that the dead skin formed a crater or rotted through to the muscle or bone, according to the Los Angeles Times. Doctors operated on the wrong body part, wrong patient, or performed the wrong procedure in 41 surgeries during that time, the paper said, citing data released from the state health department. Another 145 patients had foreign objects left in their bodies and 34 died while under anesthesia.

The public release of the data is the first disclosures under a state law requiring hospitals to inform regulators of all incidents of substantial patient harm, the paper said. The state Department of Public Health has so far fined 10 hospitals that reported adverse events a total of $25,000.

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