More people die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or AIDS.
Institute of Medicine, 1999
To Err is Human: Building a Safer Health System
In 2004, largely in response to the 1999 IOM report, the Florida legislature established the Florida Patient Safety Corporation (FPSC), whose purpose was to monitor patient safety throughout the state. An important goal of the FPSC was to establish a voluntary Near Miss Reporting System, based on a successful system used in the commercial aviation industry. The system was intended to provide immunity from legal penalties and sanctions (Florida Statutes, 2004; FL OPPAGA, 2006).
In 2004 two amendments to the state constitution were passed by Florida voters: the Patients’ Right-to-Know About Adverse Medical Incidents Act (known at the time as Amendment 7, but now Article 10, Section 25 of the Florida Constitution); and the Three Strikes and You Are Out Act (Amendment 8) (Florida Senate, 2007).
Writing the following year for “AHRQ: Morbidity and Mortality Rounds on the Web,” Paul Barach noted that Amendment 7 had eliminated the confidentiality provisions, allowing full access to all patient records, meetings, morbidity and mortality conferences, root cause analyses, and any other professional exchanges of information related to a patient’s injury or death. Brach noted that risk management professionals said that Amendment 7 had done immense harm to quality assurance and peer-review protections developed over the previous twenty years and caused an immediate decline in the reporting of adverse events throughout the state. Amendment 8 also had an unintended chilling effect on the reporting of near misses and adverse events (Barach, 2005).
The two amendments to the state constitution did indeed introduce a great deal of confusion and uncertainty into the Florida medical errors situation and they exacerbated an already recognized issue with under-reporting of adverse events. Approximately three dozen court cases were filed in the four years following the passage of Amendment 7, with lower-court decisions ruling both for and against the release of information. In 2008 two cases eventually found their way to the Florida Supreme Court, which rendered its decision in favor of Amendment 7 in both cases (Florida Senate, 2008; Rosenfeld, 2008).
Since 2004 the FPSC had followed its legislative mandate to establish itself as a working entity until it was repealed in 2009. It acquired preliminary certification as a Patient Safety Organization (PSO) from the Agency for Healthcare Research and Quality (AHRQ) and created the Near Miss Reporting System.
In 2008 the FPSC officially endorsed a private program called SorryWorks!, an independent disclosure consultancy firm, as an effective method for addressing medical errors. The goal of SorryWorks!, which is still in operation, is to establish a process that involves an initial disclosure, close contact with the patient and family, and a resolution that includes open communication. The main points are to disclose and compensate quickly when an error has occurred, vigorously defend medically appropriate care, and learn from mistakes (PSQH, 2008). According to the Sorry Works! website, Florida is one of thirty-six states with an “apology law” on the books, but these vary widely from state to state (SorryWorks!, n.d.).
State funding for the FPSC ended after the 2007–2008 fiscal year, and the first casualty was the Near Miss Reporting System. Part of its establishing legislation required it to obtain grants and other private funding to fully support itself. It was never able to do so; and, in fact, the FPSC believed that some funding should always come from the state as a show of support for its mission (Florida Senate, 2007).
Although the state Office of Program Policy Analysis and Government Accountability (OPPAGA) recommended the corporation continue and extend the exceptions allowing confidentiality of reports, it was unclear how the latter would fit with the Florida Supreme Court decisions regarding Amendment 7. On January 29, 2009, the FPSC Board of Directors voted to seek repeal of the statutes establishing the corporation and this was accomplished in May 2009 (Florida Senate, 2009; FL OPPAGA, 2006; Florida House, 2009; Florida Senate, 2009a; Laws of Florida, 2009.
Reports in the Florida media in 2011 suggested the system remained in a state of paralysis, in part due to conflicts (or perceived conflicts) between state and federal laws and in part because the apparent refusal of some hospitals to make available reports of adverse events. The situation, however, was and still is extremely complex, and the issues and laws vary depending on who is requesting what information and for what reasons.
The Florida General Counsel’s Office, on July 1, 2008, notified risk managers that information reported to the Florida Agency for Health Care Administration under state law was exempt from Amendment 7 mandates. For PSOs, such as the Patient Safety Organization of Florida Inc., formed in 2009, federal law supersedes state law in providing confidentiality for records (CBS Local Media, 2011; Florida General Counsel, 2008; PSOFlorida, 2009).
It appears that the Patients’ Right-to-Know About Adverse Medical Incidents Act in the 2015 Florida Statutes remains unchanged. The law says, in part:
Florida requires that all licensed healthcare facilities establish an internal risk management program that includes:
Details of these sections contain requirements for licensing and training; any specific limitations, definitions of reportable events; and the encouragement of innovative solutions to the problem of medical errors. Additional sections of state law stipulate facility reporting requirements, and requires that the Agency for Health Care Administration (AHCA) post summary reports and trend analyses, covering the eight most serious adverse incidents at least quarterly as well as an annual report of all adverse incidents (Florida Statutes, 2015a).
In addition, a separate section of state law requires the Florida Agency for Healthcare Administration to collect data on hospital-acquired infections (Florida Statues, 2015a). Florida became the first state to publish a hospital-specific report on hospital-acquired infections (HAIs) in 2005. However, a March 2010 review by the Committee to Reduce Infection Deaths noted that the Florida reports were disappointing due to weaknesses in data collection, detail, and methodology (RID, 2011).
In 2011 the Florida Department of Health announced it received funding from the American Recovery and Reinvestment Act to develop a Healthcare-Associated Infection Prevention Program intended to help monitor and prevent these infections. Its status on infection rates as compared to the national baseline is accessible from the CDC (CDC, 2015a).
Source: CDC, 2015. Click here or on the image to view the full-size graphic.