Report on Patient Safety Buried by State Officials

Report on Patient Safety Buried by State Officials

New York has a patient-safety advisory committee that was created 12 years ago to stem hospital errors, publicize doctors’ practice histories, and prevent medical deaths.

That committee reportedly issued a 2011 report in December 2010 with recommendations for improving patient safety from a consortium of doctors and pharmacists.

I say “reportedly” because the New York state health department and other state officials refuse to even acknowledge such a report, let alone share the contents.

In the past, these annual doctor and pharmacist reports were been reviewed by the health department and then shared with health providers, the legislature and the governor.

However, state officials maintain that these allegations of hiding or burying a report are false.

Further, they accuse the committee’s leaders of being unresponsive to health officials’ efforts to organize and focus the various committees on patient-safety, created by the Health Information and Quality Improvement Act – which was signed into law by Governor George Pataki in 2000.

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The Blame Game

There is debate about who is to blame for this disagreement.

A health agency spokesperson said that early last year a new director for patient safety reached out to the leaders of these advisory committees to re-align priorities, but it was clear that there was no interest in the committees to change anything.

The spokesperson, Bill Schwarz, claims that the agency wanted to improve things like coordination, effectiveness, and efficiency, as well as update the priorities.

But a pharmacist with the Patient Safety Center, Edward Dombroski, sent a memo in February to state health officials complaining that the advisory committee’s 2011 recommendations were ignored.

He said the response was that the recommendations would not be shared with anyone, including the governor and legislature, and the reason given was they are “not important.”

Dombroski had disagreements with health officials before, including last May when he emailed three officials urging them to share information about a particular drug, Vivitrol.

State officials said his studies and conclusions on Vivitrol were not connected to the advisory committee and that such a study requires prior approval.

End of the Committee?

Dr. Denia Varrasso, a physician and chair of several of the advisory committees, said she and other members were told recently by Commissioner Nirav Shah that the agency was going in “a different direction” and the committee was no longer required.

It seems state officials want them to just go away quietly.

Internal correspondence shows that committee members tried unsuccessfully to schedule meetings with the agency’s directors at least ten different times between December 2010 and May 2011.

The members tried again earlier this year after a Consumer Report showed a drastic decline in performance at New York hospitals.

Bottom Line

With medical errors occurring 15 million times a year, according to estimates from the Institute for Healthcare Improvement, New Yorkers can hardly afford a petty bureaucratic spat to hinder improvements to patient-safety in our state.

As a New York medical malpractice attorney  I deal with victims of this harm everyday, and this squabbling is helping no one.

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