Half of U.S. Hospitals Violate Law By Not Reporting Disciplined Doctors

Not reporting the information may also allow them to escape disciplinary action within their own states because reporting is required to state medical boards too. "In New York State, for example, 31% of hospital complaints, compared to only 10% of consumer complaints to the Board, result in a medical board action. Failure of hospitals to discipline or report therefore deprives the boards of critical information and creates the potential for patient harm," Wolfe wrote in a letter to Sebelius.

When the data base was launched in 1990, the HHS estimated that 5,000 reports would be submitted each year. The average number has been only 650 and the most ever filed was 830, in 1991.

The rule's focus "is on those instances in which physicians injure patients through incompetent or unprofessional service, are identified as incompetent or unprofessional by their medical colleagues, but are dealt with in a way that allows them to continue to injure patients," according to a House Committee on Energy and Commerce report that predated the regulation.

As examples of physician behavior that went undisciplined and unreported to the national database, resulting in further damage to more patients, Wolfe's report described these incidents:

"An orthopedic surgeon in Cambridge, MA with a history of disruptive behavior and two brushes with the law never underwent peer review until July 10, 2002, when he left the operating room seven hours into a complex back surgery–with the patient under anesthesia and an open incision in his back–to cash a check.

"A physician who had been charged with drug addiction and incompetence had his medical license suspended in Oklahoma and revoked in Texas. In 2001, he was practicing in Hawaii, and during a surgery on a man to stabilize a disc injury, used a screwdriver because he couldn't find a titanium rod. The patient was left bedridden, incontinent, and paraplegic, and subsequently died.

"In one of the most egregious recent examples of the breakdown of hospital peer review, two physicians at Redding Medical Center in Redding, California, performed clearly unnecessary bypass and valve surgeries between 1992 and 2002 on hundreds of patients," Wolfe said.

"Peer review of the cardiac program and discipline of these physicians was not done because of the 'prestige' of one of the physicians involved and the revenue for the hospital generated by the surgeries. Furthermore, although both state and Joint Commission surveys had identified peer review deficiencies at Redding, there was no oversight follow-up."