More than 1,200 adverse-event reports have been filed by Connecticut hospitals since the law was changed in 2004, including at least 116 in which patients died. About one in four are investigated, down from half of cases investigated before the law was revised.
The Department of Public Health launched investigations in most cases in which doctors performed surgery on the wrong body part or the wrong patient, as well as cases in which patients were killed or seriously harmed as the result of a medication error.
But state officials investigated only about half the reported sexual assaults on patients, and half the cases in which sponges or other foreign objects were left inside patients after surgery.
The most commonly reported problems — falls or surgical perforations that cause death or serious injury — also are the least frequently investigated. Only about 10 percent of serious falls were investigated. And of more than 200 reports of perforations during surgery or endoscopic procedures, about 15 percent led to investigations.
For the fraction of cases the department pursues, investigators almost always find multiple violations of state laws and regulations. But hospitals rarely face sanctions.
From 2005 through September 2009, the department conducted nearly 300 investigations based on adverse-event reports, with deficiencies found in all but a handful of cases. But during the same period, the department imposed cash fines against hospitals fewer than 25 times. Most of the fines ranged from $8,000 to $25,000, with two high-profile exceptions in 2005: a $250,000 penalty against Connecticut Children's Medical Center and a $100,000 fine against Hartford Hospital — both after multiple deaths or serious injuries.