Utah’s Health Department brags that the state has a great patient safety history, but the reality is not low numbers, but rather, low accountability. The Institute of Medicine conservatively figures that if Utah were average, there’d be 300 deaths a year. But the state officials who are supposed to track these things hear of only 30 cases or so a year –and that involves everything, not just deaths.
Itwould be hard to say if area facilities have a high or low number of errors, because no one’s reporting –and they don’t have to. But the state goes one step further and actually PROTECTS facilities from accountability, in the name of boosting reporting, which clearly isn’t having that effect. And, when asked, they admit it with a little embarrassed shrug. Is the patient being well served? The state doesn’t know. And patients can’t make good decisions because they have no access to any information.
The real kicker was discovering that the state has put itself in a position of having to be invited to participate in analysis of serious mistakes and or outcomes. Facilities can just shut the state out. And if the state safety person disagrees with the root cause analysis –or thinks it’s shoddy –there’s nothing with teeth it can do. It can send them a letter, but there’s no mechanism for follow up or change
Still, nothing’s simple. In part, the story turned out to be an attempt to explain to readers and healthcare consumers that negative reports are not a reason to avoid a hospital–it means that facility’s paying attention. No reports, however, may be cause for concern.