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Non-punitive system is best bet for patient safety

Providing patients with the safest possible care is the top priority of hospitals in Connecticut. We are fortunate in this state to have excellent hospitals, offering highly skilled health care providers and the latest technology. All Connecticut hospitals are deeply committed to patient safety and to being accountable for the care they provide.

Building a culture of safety is central to the mission of Connecticut's hospitals. As part of this culture, adverse events - undesirable, usually unanticipated events such as patient falls - are quickly reported and thoroughly investigated to help hospitals learn from the event. Legislation currently before the General Assembly, though, would impede the safety culture hospitals have worked so hard to cultivate.

Senate bill 248, "An Act Concerning Adverse Events at Hospitals and Outpatient Surgical Facilities," would change the way adverse events are reported in Connecticut. The bill proposes to alter Connecticut's adverse event reporting system and increase its punitive aspect by imposing fines on hospitals.

On the surface, this may appear to be a good idea, but a punitive reporting system does nothing to make patients safer, and will actually make it more difficult to spot problems and prevent adverse events from happening in the future.

As we have learned from the well-documented experience of the aviation industry, confidential reporting is fundamental to safety improvement. After several tragic accidents in the 1970s, the airline industry instituted a confidential reporting system, resulting in far fewer accidents and improved safety performance. In health care, confidential, non-punitive adverse event reporting systems serve the best interest of the patient by encouraging reporting, which is essential in eliminating future adverse events.

Connecticut's adverse-event reporting law is based on the National Quality Forum's list of 28 serious reportable events, supplemented by six Connecticut-specific reportable events as defined by the Department of Public Health (DPH). Every hospital in Connecticut has an adverse-event reporting system in place. When an adverse event occurs, it is reported by the hospital to DPH, as required by law since 2002. DPH aggregates these events to protect the confidentiality of the hospital and issues an annual adverse-events report, which is available to the public.

Our hospitals are working continually, individually and collectively, to identify opportunities to improve patient safety. We are especially proud of the work hospitals do together through the CHA Patient Safety Organization (PSO), where we focus on statewide efforts to improve the quality and safety of patient care. Through the PSO, we have convened several clinical collaboratives - multi-hospital, multi-disciplinary initiatives - and over the past few years, these collaborative teams have made remarkable progress. Collaboratives addressing the most commonly reported adverse events - falls with injury and pressure ulcers (also known as bed sores) - have led to significant improvements at hospitals throughout the state.

CHA and its member hospitals support adverse-event reporting as an important tool in keeping patients safe from preventable harm. Any changes to the current adverse-event reporting system must be carefully considered, must not be counterproductive to the goal of patient safety, and must provide information that is useful to patients. A confidential, non-punitive system encourages reporting, which is essential to eliminating future adverse events. We look forward to working with the legislature's Public Health Committee and its chairs to ensure the adverse-events reporting system promotes the best interests of patients in Connecticut's hospitals.

Jennifer Jackson is chief executive officer of the Connecticut Hospital Association.


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