Though a Washington state judge said a guardian ad litem failed to do her job, by then, the child’s mother says, the damage had already been done.
Incarceration rates are rising, and inmates say they’re being punished for the state’s failures to manage prison capacity
Loopholes and failed investigations allowed a former Henry M. Jackson High School teacher to skirt accountability
Peter Korn of The Portland Tribune released an interesting article revealing that Oregon hospitals, nursing homes and pharmacies are reporting few of their medical blunders, according to a recent Oregon Public Health report. The article arrives not long after Hearst Newspapers released an extensive review of the nation's inconsistent reporting of medical errors, which they found contributes to thousands of preventable deaths and injuries every year.
Oregon's unique system for reporting health care mistakes relies on voluntary participation. While nearly every hospital is a member of the patient safety commission, less than 10 percent of Oregon's pharmacies have agreed to participate and the commission has yet to request reports from them.
But while the statistics show that hospitals are still reluctant to confess to their boo-boos -- with 27 percent of hospitals yet to report a mistake to the commission -- the number of reported events did increase, by 14, from 2007 to 2008.
Grant Higginson, Oregon's public health officer representative to the patient safety commission, believes that the commission is making headway:
This really is a culture change, a shift from people being afraid because they’re going to get punished for making a mistake, to a culture where you learn from mistakes and you use the information to change systems, rather than reprimand people... It’s going to take some time.
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Though a Washington state judge said a guardian ad litem failed to do her job, by then, the child’s mother says, the damage had already been done.
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Loopholes and failed investigations allowed a former Henry M. Jackson High School teacher to skirt accountability
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