Senate Probes Reasons for Adverse Hospital Events

They are events that leave patients worse off than when they first come to the hospital — from “never events” such as leaving surgical devices in a patient after an operation, to the acquisition of MRSA (methicillin-resistant Staphylococcus aureus), a highly resistant bacterial infection.

“I believe that the DPH (California’s Department of Public Health) has not been actively pursuing the reporting of adverse events within the five days required by statute,” Senate member Elaine Alquist (D-Santa Clara) said. “Now, I don’t know if we’re talking fines or not, but I do know the system is not working.”

Alquist is chair of the Senate panel that convened yesterday and gathered representatives from state health agencies, hospital associations and patient advocate groups to discuss reporting and preventing adverse events in California hospitals.

The first step is to contact all of the hospitals to make sure they’re in compliance, according to Kathleen Billingsley of the state DPH.

“I do not believe it’s an act of deliberate non-compliance,” Billingsley said. “We are sending letters to the CEOs of hospitals to make sure they know that they need to conduct an assessment of adverse events.”

The department has arranged a number of in-person visits, as well. “We have visited 204 hospitals so far, and we will send additional staff to target these hospitals.”

The legislative panel had one breakthrough when discussing transmission of MRSA.

According to several members of the panel, a key component of getting hospitals to improve their MRSA prevention efforts is to have public reporting of deficiencies, a process aided by good online reporting tools. The state’s online reporting tools were criticized as inadequate.

“You have to fix the [DPH] website,” Betsy Imholz of Consumers Union said. “Research shows that’s what drives improvement.”

But according to Billingsley, the department’s strength is in health care experience and knowledge, not in website design. “I’ve been working on it with one other person in the department,” she said, “but we’re not really qualified to build a website. And that’s a big piece of it, we’re not experts, we don’t have the resources to do this.”

Senate member Alquist pointed out that Billingsly said earlier in the meeting she did have enough resources. But, it turns out, Billingsley can’t use some of those resources yet.

“We are currently in a hiring freeze,” she said. “So there is an opportunity there, and we hope to fill that position soon. But right now we’re unable to fill that position because of the hiring freeze.”

“You cannot contract out the work?” Alquist asked.

“Yes. Yes, we could contract,” Billingsley said. “We could do that.”

“Well,” Alquist said. “That’s one part solved.”

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