Public reporting of adverse health events welcome [Commentary]

A recent Baltimore Sun article ("Maryland hospitals aren't reporting all errors and complications, experts say," July 26) focused on the benefit of facility-specific adverse medical event reporting to state regulators to improve patient safety, enhance consumer decision making and increase health care facility accountability. The article noted that reporting of "adverse events" — including wrong site surgery, surgeries on the wrong person, medication errors and assaults on patients — is not made public in Maryland. The article goes on to suggest that a lack of information sharing among the Office of Health Care Quality (OHCQ), the Health Services Cost Review Commission (HSCRC) and the Maryland Health Care Commission (MHCC) has produced discrepancies in the number of infections reported by the three agencies.

All three of the agencies named in the article support public reporting of cost and quality information. Each organization has a specific role in oversight of health care facilities in Maryland, although none of the organizations is currently authorized to publicly report on adverse medical events as is done in Minnesota, New York and several other states.


OHCQ monitors the quality of care in Maryland's approximately 14,000 health care facilities and community residential programs, including hospitals. The agency annually performs more than 350 hospital investigations and surveys in response to consumer complaints, facility-reported incidents and other inquiries. Deficiencies of federal and state law resulting from these investigations are available for public disclosure.

In 2004, Health General Article §19-304 was passed; it mandated that hospitals report all Level 1 adverse events — those that resulted in death or serious disability — to OHCQ as well as a root cause analysis of the event. Although the regulations do not require public disclosure of these specific events and the related root cause analysis, hospitals are required to disclose to the patient if they have been a victim of an adverse event. To ensure compliance with these regulations, OHCQ reviews the root cause analyses, conducts complaint investigations and surveys for evidence of possible adverse events that were not reported, and reviews quality and performance data. Lessons learned and best practices are shared through Clinical Alerts, an annual Maryland Patient Safety Program report and presentations.


HSCRC, Maryland's hospital rate setting agency, collects information on care provided to all patients treated in Maryland hospitals — including data on 65 potentially preventable complications, among them hospital-acquired infections, including bloodstream, or catheter-associated, infections. Hospitals having higher than expected infection rates are penalized through reductions in reimbursement rates approved by HSCRC.

MHCC develops the Hospital and Nursing Home Performance Guides to increase transparency, highlight good and poor performance and support consumer decision-making. To do this, MHCC uses consumer satisfaction surveys and other data on common medical conditions, maternity care and treatment of newborns in the Maryland Hospital Guide.

The discrepancies in the number of hospital-acquired infections cases reported by the three agencies, as noted in The Sun article, reflect the distinct roles of the agencies, rather than demonstrating incompatibility in reporting. Infections of all kinds acquired during hospital visits are a great concern as they impede recovery and increase costs.

HSCRC uses billing data to estimate the total number of hospital acquired infections. MHCC uses a more precise surveillance system, focusing just on catheter-associated infections in the intensive care and neonatal intensive care units, where consequences to patients can be most serious. OHCQ's patient safety program only includes catheter-associated infections that resulted in death or serious disability.

Despite differing approaches, the collaboration of these three agencies in the monitoring of infections has meant fewer catheter-associated infections over the last 4 years. It is possible that applying this same collaborative approach could reduce the overall number of adverse medical events in the state's health care facilities. The three agencies agree and are prepared to implement a broad adverse event public reporting system, should the General Assembly vote to implement such a system in Maryland.

Ben Steffen is the executive director of the Maryland Health Care Commission; his email is Donna Kinzer is executive director of the Health Services Cost Review Commission; her email is Patricia Tomsko Nay is executive director of the Office of Health Care Quality; her email is

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