Last year, healthcare providers in Oregon reported 704 adverse events to the Oregon Patient Safety Commission's Patient Safety Reporting Program — the largest number of adverse events reported to the PSRP since it started in 2006.
The PRSP collects medical error reports from hospitals, ASCs, nursing facilities and pharmacies. Of the events reported from those entities last year, 48 percent resulted in serious harm or death.
Falls were the most common event type reported across all care sites, making up 25 percent of adverse events. The other top event types were medication or other substance events (15 percent), surgical or other invasive procedure events (14 percent), and care delay (9 percent).
Entities also reported on factors contributing to the adverse events. In hospitals, those factors include:
- Communication (68 percent)
- Policies or procedures (65 percent)
- Patient factors (62 percent)
- Organizational factors (61 percent)
- Patient management (56 percent)
- Human or environmental factors(55 percent)
- Devices or supplies (48 percent)