Illinois medical error reporting law to be implemented

By Lindsey Tanner

Ten years ago, a landmark report said medical mistakes kill up to 98,000 Americans yearly. In 2005, Illinois legislators decided to do something about it and passed a measure requiring hospitals to report the deadliest kind.

Four years later, the law has yet to be implemented — and it likely won't be for at least another year.

State budget woes and foot-dragging by special interests are among reasons cited for the long delay. But there are finally glimmers of progress. That includes the recent launch of a related state Web site that tracks hospital infection rates and staff levels, and the imminent start of a search for a vendor to help put the law in place.

The law will require hospitals to publicly report so-called "never" mistakes. These are mostly preventable errors with potentially life-threatening consequences — like the wrong-knee surgery Krzysztof Kordes says Chicago-area doctors performed on him last year or the forgotten sponge left inside a Plainfield woman during breast tumor surgery.

"It just should never have happened," Margaret Forsberg said of her botched 2004 operation. When the sponge was found, almost two months later, veins had grown around it, requiring more invasive surgery to remove it, said Forsberg, who sued and settled with Edward Hospital in Naperville.

When the Illinois Adverse Health Care Event Reporting Law is fully in place, hospitals will be required to report major medical errors within 30 days to the state's public health department.

An annual list of hospitals and mistakes will be posted online. Hospitals also will have to determine how mistakes happened and develop a plan to prevent others.

The Joint Commission hospital regulatory group requires hospitals it accredits nationwide to take similar action, but its reporting program is voluntary. About 800 major medical errors were reported last year. The numbers have increased steadily in recent years, though that may reflect more awareness among doctors and hospitals rather than more errors.

One of the most common major errors is leaving surgical sponges inside patients. Edward Hospital this month adopted a new prevention system, equipping all surgical sponges with radio frequency microchips. Patients are "wanded" to detect stray sponges before surgery ends.

Brian Davis, an Edward vice president, said Forsberg's sponge incident didn't prompt the new system, and he declined to comment on her case. The hospital supports the reporting law, he said.

Doug Wojcieszak, founder of The Sorry Works! Coalition, a Glen Carbon, Ill.-based advocacy group, called the law "a good first step, but not a final solution. The mere fact it is taking so long for the law to become operational shows the hurdles we still face."

"We must educate hospitals and medical professionals that sharing more, not less, information benefits everyone, providers included, after an adverse event," Wojcieszak said.

David Carvalho, the state public health department's policy director, says hospitals have been worried that the law might prompt more lawsuits, and advocacy groups claim the Illinois Hospital Association worked to delay implementing the law.

Howard Peters, the association's senior vice president for government relations, disputed those claims and said the group supports the law.

"There needs to be a process by which errors are reported and by which hospitals and doctors can learn from the misses and near-misses of others," Peters said.

However, the association objected earlier this year to proposed rules, including a requirement that hospital reports indicate whether anyone apologized to the patient or patient's family.

The department modified the language to clarify that apologies weren't required.

The next step in implementing the law is a Dec. 17 meeting of a state advisory council, where members will start seeking a vendor to set up an electronic reporting system. Then, a required six-month pilot period can begin to test the system and fix any kinks.

While errors won't be publicized until the law is fully enacted, consumers will benefit when the testing period begins because hospitals will be forced to take corrective action, said Linda DeLaforgue of Citizen Action Illinois, a consumer advocacy group.

Still, finding a vendor can take several months. In the best-case scenario, the test phase won't begin until mid-2010, and it's likely the law won't be fully in place until 2011, Carvalho said.

Illinois' efforts to improve the reporting of medical mistakes and other health information are part of a national patient safety movement prompted by a 1999 Institute of Medicine report on the scope of medical errors.

Minnesota was the first state to adopt a comprehensive medical error reporting law, in 2003; Illinois' law and reporting measures in a handful of other states are patterned after Minnesota's.