But these documents "have never been shared by the state. And after repeated efforts to get a data use agreement, we were not given access to some of the information we thought we would," he says.
Kizer says he needs details show underlying causes and trends. "Do you have the brand name of the device that was used to cauterize? In some of the records, there's nothing like that; it says 'during cautery, a fire happened.' That satisfies the regulatory requirement for reporting. But for quality improvement purposes, you want to know the brand, make, and manufacturer, and [whether there] was there oxygen in use in the room."
"We're analyzing the many hundreds of adverse events, trying to make sense of those, determining which are the most frequent, who do they involve, where do they happen, and whether they are more frequent in some areas than others," Kizer told me.
He says he's asked for a six-month contract extension, until mid-2015, to allow another year's worth of adverse event data to be folded in, to give the report more statistical power.
When complete, he says, "this will be the largest analysis of surgical adverse events that has been done anywhere in the country, substantially larger than what the Centers for Medicare & Medicaid Services gets, or at least what is made public."