In 2003 Pennsylvania legislatively passed what was then called “Tort Reform” again attempting to limit the rights of victims of medical malpractice. Part of the legislation which was offered to make the grim restrictions more palatable created a Patient Safety Authority. Hospitals were required by law and under threat of fines of up to $1000 a day if they failed to report serious events taking place in their institutions.
The statute which created the Patient Safety Authority clearly and simply defined what represented a “serious event”. Any unexpected result of a medical intervention resulting in injuries requiring further medical care is a “serious event”.
In addition to reporting the occurrence of a serious event to the Patient Safety Authority the institution involved was also required to promptly inform the patient or patient’s family that a serious event had occurred, the nature of the event and to encourage honesty in reporting, patients receiving in serious event letters were not allowed to use the letters or anything contained in the letters in any civil action.
The purpose of reporting the events to the Patient Safety Authority was to encourage dialogue which might result in avoiding the occurrence of certain kinds of injuries, e.g. operating on the wrong leg.
Michael Doering, Executive Director of the Patient Safety Authority on November 22, 2011, informed this author that the Patient Safety Authority had no power to enforce the reporting requirement for serious events.
This bizarre state of affairs was revealed to me as a consequence of my representation of a patient who went in for bypass surgery who had vein grafts harvested from his leg, who had the misfortune of a physician’s assistant having harvested instead the patient’s saphenous nerve. The required report in writing to the patient of this serious event did not and has not occurred and the event has also not been reported by the hospital involved to the Patient Safety Authority. The Patient Safety Authority has expressed no concern to me about the occurrence of the event, their having no knowledge of the event, the event having not been reported in violation of law or them having no power to enforce the law (according to them).
The Patient Safety Authority has forwarded the complaint I made to them to the Health Department. I have heard nothing from them and I have a letter from an attorney representing the involved hospital admitting a serious event letter was not sent.
Does anyone else think this is a farce? Does anyone care?