Report: California lagging on patient safety


March 17, 2010

Consumers Union Finds Slow Progress on Patient Safety in California

California Department of Public Health Has Failed to Carry Out
Key Requirements of Recent Patient Safety Laws

SAN FRANCISCO, CA – Since 2006, California lawmakers have passed a number of laws aimed at holding hospitals accountable for reducing medical errors and patient infections. But a report by Consumers Union has found that the California Department of Public Health (CDPH) has been slow to implement a number of key provisions of new patient safety laws.
“Californians deserve to know if their local hospital is doing a good job preventing medical errors and infections,” said Lisa McGiffert, Director of Consumers Union’s Safe Patient Project ( “But even though California has adopted a number of laws to shine the spotlight on each hospital’s track record, the state has dragged its feet implementing these patient safety reforms. As a result, Californians remain in the dark about how well hospitals protect patients from sometimes deadly medical errors and infections.”
An estimated 240,000 Californians develop hospital acquired infections each year, resulting in 13,500 deaths and a cost of $3.1 billion. Medical errors kill as many as 10,000 Californians annually and injure 140,000. These errors include so-called “never events” because they can always be prevented and should never happen.
Consumers Union met with CDPH officials in December 2009 to find out what the agency had done to implement recently adopted patient safety laws. The Department did not respond to a December follow-up letter by Consumers Union requesting additional information. On February 16, Consumers Union submitted a public records request to compel the Department to respond, but has not received this information yet. The Department has missed the deadline required by law for responding to the public records request.
Based on the information Consumers Union has gathered thus far, it appears that the Department has failed to carry out important provisions of recent patient safety laws:
Establishing hospital infection prevention program: By January 2008, the Department was required to establish a hospital acquired infection (HAI) surveillance and prevention program but didn’t begin creating it until September 2009. The Department recently indicated that it has just hired staff. The Department’s program seems to emphasize coordinating efforts to help hospitals learn from each other and focuses on just a few infections rather than training its own staff and monitoring hospitals’ compliance. After establishing a HAI advisory committee as required by law in January 2007, the Department disbanded it two years later before it had finished its work.
Collecting & reporting data on infection prevention measures: Beginning in January 2008, the Department was required to collect data from hospitals on their compliance with CDC guidelines to prevent central line and surgical site infections and to vaccinate healthcare workers and patients for influenza. By July 2008, the Department was supposed to begin publishing reports detailing each hospital’s compliance record but has not done so. However, separate from the state law, surgical site infection information is available on a federal website.
Collecting and reporting data on infection rates: Hospitals are supposed to report to the Department and the CDC’s National Healthcare Safety Network the incidence of bloodstream infections caused by MRSA, C-diff, and Vancomycin-resistant enterococcal; certain surgical site infections, and central line associated bloodstream infections. But some hospitals have not signed up with the CDC to report these infections and it is unclear how much of this data has been collected so far by the state. The Department is supposed to issue its first report detailing certain infection rates at each hospital in January 2011.
Ensuring hospitals take steps to curb MRSA infections: By January 2009, the Department was supposed to establish a program to ensure that hospitals are screening certain high risk patients for MRSA and informing patients that are MRSA carriers or develop MRSA infections. However, it is unclear what steps the Department has taken to ensure hospitals are complying with these requirements that aim to reduce the incidence of MRSA infections.
Strengthening state infection prevention regulations: By January 2008, the Department was supposed to revise existing hospital infection regulations and adopt new ones to incorporate current CDC guidelines for preventing infections. But no revised regulations were ever issued by the Department.
Informing the public about reported medical errors: Beginning in July 2007, hospitals were required to report certain medical errors to the state. The Department was required to investigate these incidents, make information about them readily accessible to Californians, and fine hospitals for failing to protect patients. While the Department has been investigating reported medical errors and issuing fines, it only discloses detailed information to the public about medical errors when hospitals are fined. When fines are not imposed, the Department discloses only minimal information about reported adverse events to the public. Information about reported medical errors is difficult to find on the Department’s web site.
Inspecting hospitals to ensure compliance with patient safety policies: By January 2007, the Department was required to begin conducting unannounced inspections of hospitals to ensure that they develop, implement, and comply with medical error prevention policies. Each hospital was required to create patient safety plans by January 2009 that establish accountability and a system for reporting medical errors, reviewing adverse events after they occur, and ongoing staff training. But it is unknown whether the Department has begun these inspections.
Ensuring patients are informed when medical errors occur: Beginning in January 2007, hospitals were required to inform patients or their caregivers after medical errors occur. But it is unclear whether the Department is taking steps to ensure hospitals are complying with this requirement.
Michael McCauley – 415-431-6747