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Public and Private Policy
Medical Errors and Patient Safety


New York State has had a long history of requiring hospitals to report and initiate actions based on adverse events occurring in their facilities. These initiatives date to 1985. An emphasis on patient safety became apparent after publication of the IOM report, To Err is Human. Since 2001, New York State has dedicated more than $8 million to support health care providers statewide in developing and implementing patient safety initiatives; this funding is above and beyond substantial federal funding grants from AHRQ to the New York DOH and New York healthcare facilities for patient safety.

  • •  Early Regulatory Efforts

    Regulations in New York State requiring adverse event reporting became effective on October 1, 1985, apparently in response to a series of preventable hospital deaths. The reporting program was subsequently incorporated into legislation designed to address a medical malpractice availability crisis.

    In 1993, the mandatory incident reporting system was redesigned and renamed the Patient Event Tracking System (PETS). PETS was an e-mail system based on a decision algorithm of patient harm and therapeutic treatment. It involved subjective judgment regarding incidents through a peer review process, which led to inconsistent data. In 1995, the state convened a task force to examine ways to improve the Patient Event Tracking System (PETS).

  • •   Cardiac Surgery Reporting System (CSRS)

    Following recommendations from the New York State Cardiac Advisory Committee in 1989, The State of New York was the first of only four states (CA, NJ, NY, PA) to implement mandatory Report Cards of physician-identified and facility-identified cardiac outcomes for cardiac surgery and/or percutaneous coronary angioplasty (PCI).1 Coincident with the New York initiative, the risk-adjusted mortality rates for Coronary Artery Bypass surgery decreased significantly and to mortality levels that were less than or equal to the highest performing heart centers in the country. The Department of Health and health policy advocates attributed this phenomenon to the successful implementation of outcomes reporting programs.2, 3, 4

  • •  New York Patient Occurrence Reporting and Tracking System (NYPORTS)

    In 1998, the state passed legislation [NY PBH §2805-L(1)] and began implementing the New York Patient Occurrence Reporting and Tracking System (NYPORTS). Under PETS, hospitals used subjective decisions before reporting an adverse event to the state, but the ‘incident reporting’ initiative of 1998 provided specific examples of adverse events that must be reported to the state. NYPORTS also simplified reporting, streamlined the coding, which was based upon UB-92 Hospital administrative databases, and coordinated it with other reporting systems to reduce duplication. Perhaps most importantly, NYPORTS allowed hospitals to obtain feedback on their own reporting patterns and compare them with other facilities in the region and the State.

    Through mid-2006, two extensive and detailed annual reports (1999 and 2000/2001) have been published along with several ‘News and Alert’ Bulletins that historically have been published 2-4 times per year. NYPORTS is also actively involved in the Root Cause Analysis and risk managment reviews at hospitals.

    An audit of NYPORTS by Comptroller Alan G. Hevesi was published on September 28, 2004 [PDF], indicating that the information in NYPORTS is not complete and is not reported in a timely manner. Wide variability in reporting by hospitals suggested that persistent under-reporting was a significant issue, as evidenced by the observation that 61 (23 percent) of the 243 reporting hospitals had "occurrence reporting rates that were more than 50 percent lower than the statewide average" in both 2001 and 2002. Furthermore, the audit determined that,in many instances, the occurrences reported by the 1,350 clinics with reporting requirements . . . "were not recorded on NYPORTS, and in some instances, information about facility investigations into most-serious incidents either was not recorded, or was not fully recorded, on NYPORTS." Hospital reports constitute 99.4% of all reports in NYPORTS, according to the audit.

    Subsequent heated responses from special interest groups have used this audit as ammunition to indict the DOH for its "Empty Promises" for failing to address patient safety in a meaningful way and for failing to adequately regulate hospitals and physicians accross the state [PDF]. The DOH response to the audit is included as an attachment in the audit, voicing strong disagreement with the conclusions reached in the report.

    NYPORTS in 2006 receives significantly more reports of adverse events from hospitals than any other state, no doubt due to its aggressiveness in mandating reporting; however NYPORTS has not published annual reports since 2001, and feedback to the consumer public has been limited.

  • •  New York Patient Safety Center

    In 2000, New York State passed legislation that created a web-based statewide health information system that included a Patient Safety Center within the Department of Health. As part of this initiative, publication of several consumer-related health issues were brought together at a single Department of Health website, beginning in 2001. Among these issues were newly-mandated detailed individual physician profiles, physician and hospital Cardiac surgery performance data, hospital surveys, managed care performance, NYPORTS analyses of reported ‘incidents,’ and others.

    The information center has benefitted from a three-year (2001-2004) federal AHRQ grant totaling $5.4 million for the New York State Safety Improvement Demonstration Project, whose project goals included identification of the causes of preventable errors and patient injury in health care through the root cause analysis process and the development, demonstration, and evaluation of strategies for reducing errors and improving patient safety through hospital interventions.

  • •  Niagara Coalition Implementation of IQIs

    Another component of the NY Patient Safety system resulted from a regional implementation of AHRQ's Inpatient Quality Indicators (IQIs) to provide patients/consumers with access to credible, uniform information that reflects quality. The New York State DOH has funded regional pilot projects to publish hospital quality indicators, and perhaps the most successful of these funded initiatives was developed in the western part of the state by the Niagara Health Quality Coalition (NHQC). The Niagara Coalition was established in 1996 and has strong representation of business, labor, health plans, hospitals, and physician providers. Building upon a pre-existing patient survey project (the NHQC Patient Survey Project©) and a hospital report-card profiling project started in 1998 with Automakers' and Autoworkers' participation, the NHQC collaborated with its partners and others (including the NY State Department of Health) to form the Alliance for Quality Health Care (AQHC), which annually published state-wide hospital quality report cards using the AHRQ IQIs. Niagara currently publishes these report cards with grant funding.

    The reports for 25 of the 34 IQI measures are available at website, which provides bar-graphs with confidence intervals for each of the 25 IQIs. In addition, for those users less inclined to interpret statistics, a ‘3-star’ methodologic representation of quality indicators is provided. (It awards hospitals that perform above or below 95% confidence intervals with 1 and 3 stars respectively, while all other hospitals are given 2 stars.) No opportunity for trending data yet exists. The website also provides Patient Satisfaction survey information, HMO evaluations, and links to other initiatives addressing quality performance measurement in New York. The Niagara Coalition production of state-wide data has not been incorporated or linked to the New York State Patient Safety Center, but it reflects another effort within the State of New York to quantify quality and report patient safety to the public.

1  Web publication of cardiac procedures identifying facilities only has been implemented in Massachusetts, Ohio, Rhode Island, and Virginia.

2  Chassin MR, Hannan EL, DeBuono BA. Benefits and hazards of reporting medical outcomes publicly. N Engl J Med 1996;334:394-8. – [PDF]

3  Contrary to public health experts, a majority of surveyed cardiac surgeons in New York (62%) admitted to refusing to operate on at least one high-risk CAB patient in the prior year, primarily because of potential adverse public reporting, while simultaneously greater proportions of high-risk CABG surgical candidates were denied operative intervention. [Burack JH, Impellizzeri P,Homel P, Cunningham JN, "Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons," Ann Thor Surg, 1999(Oct); 68(4):1195-200; discussion 1201-2. – PDF] These data are similar to findings in Pennsylvania where 63% of surgeons reported being "much less willing," or "less willing," to operate on severely ill patients. [Schneider EC, Epstein AM. Influence of cardiac surgery performance reports on referral practices and access to care: a survey of cardiovascular specialists. N Engl J Med 1996;335:251-6. – PDF]

4  In addition, reports documented travel of high-risk surgical patients to out-of-state facilities lacking provider report cards for surgery [Omoigui NA, Miller DP, Brown KJ, et al. "Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes." Circulation 1996;93:27-33. – [PDF]. This observation was not validated in a subsequent independent analysis. [Peterson ED, DeLong ER, Jollis JG, Muhlbaier LH, Mark DB. "The effects of New York's bypass surgery provider profiling on access to care and patient outcomes in the elderly." J Am Coll Cardiol 1998;32:993-9. – PDF]

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