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The recent 2009 Hospital Performance Report conducted by the New Jersey Department of Health and Social Services (DHSS), which grades each hospital on the state on the quality of its health care services, found that New Jersey doctors, nurses, and other health care workers committed almost 9400 preventable medical errors in 2007.

In the wake of this report, the Office of the Inspector General (OIG) examined 17 different health care adverse event-reporting systems across the country. While New Jersey’s system ranks among the top in the country, many states are holding onto systems that share too little information with the public, and some states, including Utah, Florida, Nevada, New York, South Carolina, South Dakota, and Vermont, have no adverse event reporting system at all.

Moreover, the OIG found:

…there is no centralized reporting system to which all facilities can submit data to or access to review in order to learn solutions to avoid repeating those events, wrote Stuart Wright, deputy inspector general for evaluation and inspections, who signed the report.

"Rather, there are separate federal, state, and nongovernmental entities that receive and disclose adverse event information," he wrote. "Depending on the entity, reporting is either voluntary or mandatory, and the entities have different data collection procedures, privacy protections, and dissemination practices." –Health Leaders Media

What this ultimately means is that when it comes to medical errors, the right hand has no idea what the left hand is doing: states aren’t communicating with each other, with the federal government or with NGOs, and serious medical errors are being repeated over and over not only due to a lack of public accountability in many states, but due to a lack of unification when it comes to prevention. Worst of all, nearly 200,000 people are dying each year from preventable medical errors.

Congress has the wherewithal to establish a centralized reporting system for medical errors as part of the health care overhaul—why isn’t this a priority?

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