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1. Medical board backlog put patients at risk 2. Maryland nurse's license suspended after patient died 3. New Pennsylvania agency to monitor medical errors

Patient Safety Monitor Alert, August 15, 2003

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1. MEDICAL BOARD BACKLOG PUT PATIENTS AT RISK
Two physicians resigned from a voluntary panel of the Massachusetts Board of Registration in Medicine, claiming the board has failed to investigate hundreds of reports on unexpected deaths and serious injuries which occurred in Massachusetts hospitals in the past several years. The failure has put patients at risk for repeat mistakes in the facilities.

The reports included cases of patients dying in community hospitals where physicians attempted complicated surgeries or someone who died in a teaching hospital because a resident could not see the patient in time, according to news reports. Under state law, the board must to make sure hospitals investigated the unexpected deaths and took action to prevent the mistakes from happening again. Hospitals file the reports with the medical board on a quarterly basis. Most of the unread reports are from 2001 and 2002, according to Arnold Relman, MD, one of the physicians who resigned. The state board recently hired a new director to oversee review of the reports.

2. MARYLAND NURSE'S LICENSE SUSPENDED AFTER PATIENT DIED
The Maryland Board of Nursing suspended a nurse's license, alleging she failed to render appropriate care to a critically ill patient. The nurse reportedly recorded over a five hour period the dangerously low blood pressure of a 63-year-old woman in her care but failed to alert a doctor to her condition. The patient, who suffered from respiratory failure, streptococcal pneumonia, low blood pressure and septic shock, died July 6.

Montgomery County police have not formally charged the nurse for the patient's death. At a recent news conference, Shady Grove Hospital President Deborah A. Yancer said the nurse "may have taken unauthorized, inappropriate, and unilateral action" to "hasten the death of a critically ill patient or patients."

3. NEW PENNSYLVANIA AGENCY TO MONITOR MEDICAL ERRORS
The Patient Safety Authority, a new state agency in Pennsylvania, will work with ECRI and the Institute for Safe Medication Practices to track medical errors and near-misses in the state's hospitals and outpatient facilities. The state created the agency as part of an effort to address the malpractice insurance problem by reducing medical errors. The agency plans to begin operation by the end of September.

More than 350 hospitals, outpatient facilities, and birthing centers will have to report serious events involving patients as well as incidents where patients were almost harmed before staff detected the error. Organizations must report all incidents within 24 hours and face $1,000 per day fines if they do not release the information. Each facility will also have to create a patient safety committee and appoint a patient safety officer. All reports to the agency are confidential.

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