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Medical Errors and Patient Safety


The State of West Virginia has no established medical error reporting program under regulatory authority. However, West Virginia has had a voluntary reporting program for hospitals dating to 2001.

The West Virginia Patient Safety Program began in 2001 when the West Virginia Medical Institute (WVMI), the QIO for West Virginia, attempted to recruit 46 West Virginia hospitals into a voluntary program. The program was designed to include obligatory reporting with an Internet-based commercial data reporting system of all medical errors, plus voluntarily reporting of medical errors of omission and ‘near-misses.’ The recruitment initially garnered only 5 hospitals, which subsequently grew to 7 participating hospitals by 2004.

While some of the lack of participation was related to inadequate Internet connectivity, especially within smaller and rural hospitals, the major identified problems that kept hospitals from participating were

  • ◊  fear of hospital attorneys that inadequate confidentiality protections existed in current West Virginia Peer Review Protection Statutes, thereby putting hospitals at risk for discoverability of disclosed information, and
  • ◊  fear of employees of retribution for reporting of ‘near-misses’ and medical errors.

The WVMI, the West Virginia Hospital Association (WVHA), and others lobbied the legislature for greater protections for reporters and participants in medical errors reporting, and the state legislature responded with Whistle-blower protections, enacting the Patient Safety Act of 2001. In addition, the 2004 legislature, via HB4587 specifically extended peer review protections to peer review organizations that included JCAHO and other accrediting organizations.

The latter bill amended an existing Peer Review Protections law, adding patient safety review to the perview of peer review. The hospital accreditation organization JCAHO was specifically granted PRO protections, thereby addressing most of the fears and removing some of the impediments to participation by hospitals that previously indicated reluctance to participate.

Another fortuitous event that spurred the lagging participation of hospitals across the State was a successful application for federal grant funding. Beginning 9/30/2004 and extending to 9/29/2007, the West Virginia Medical Institute (WVMI), working with the West Virginia Hospital Association (WVHA), received a 3-year matching grant addressing Health Information Technology from AHRQ [# UC1 HS14920 in the amount of $1.7M. This grant was designed to extend the Patient Safety Program to Critical Access Hospitals (CAH) and other rural hospitals in West Virginia by providing dedicated computers, software, and Internet access to rural providers.

Other grant partners include the West Virginia State Office of Rural Health, Verizon, and Quantros, Inc., the software supplier.

The grant funding spurred additional hospital participation in the Internet-based reporting system. Of the 73 acute care hospitals, specialty hospitals, and health systems represented by the West Virginia Hospital Association (WVHA), 54 of them were targeted as potential participants, and the AHRQ grant specifically targeted a maximum of 24 rural and Critical Access Hospitals. Participating hospitals increased from 7 hospitals in 2004 to 27 hospitals in 2005, and this latter group included 12 of the 14 targeted Critical Access Hospitals (CAHs) in West Virginia. In mid-2006, WVMI reported that 29 hospitals have reported slightly over 20,000 events.

Along with Oregon, West Virginia is one of two states with entirely voluntary medical error reporting programs. The West Virginia program, which has no participation of regulatory authorities, provides no public disclosure and/or reporting. Furthermore, root cause analyses and development of action plans in response to reporting of errors are not obligatory, although these actions are recommended as part of JCAHO's voluntary sentinel event reporting program. In contra-distinction, Oregon has participation of the Oregon Patient Safety Commission, which is a non-regulatory 'semi-independent state agency,' and much of the maintenance costs for the program will be borne by the participating healthcare facilities. Oregon facility participation requires root cause analysis and development of action plans in response to errors. Like West Virginia, no facilities are identied in Oregon, but unlike West Virginia, Oregon requires annual reporting of aggregate facility information to the legislature and the public.

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