The Oregon Patient Safety Commission released the findings this week in a 16-page state report on medical harm in the past five years, calling it “the first comprehensive review of post-pandemic patient safety data in Oregon.” The Oregon Legislature created the agency in 2003 with the goal of providing an advocate for patient safety while incorporating the perspectives of medical providers, insurers and consumers.
The survey found that 30% of Oregonians have reported experiencing some form of medical harm in the past few years, whether that involved their own care or “someone close to them.” Medical harm is a broad category that can encompass a wide variety of improper practices or mistakes by doctors and medical providers, which may spiral into further inaccurate treatment plans.
Nationally, studies have shown that around 400,000 hospitalized patients annually experience some form of preventable medical error, while preventable deaths are pegged at around 200,000. And in Oregon, only around 21% of hospitals met the highest safety grade offered by an industry watchdog group as recently as spring 2025. It’s a significant decline since 2020 and puts Oregon in the bottom third of states nationwide for hospital safety.
The new research from the state’s patient safety commission did not just track hospital facilities, and it avoids spelling out specific anecdotes or instances of provider error. The agency reported 52% of incidents occurred in a hospital setting, 31% in primary or specialty doctor offices, 7% in urgent care and 6% in nursing homes.
The findings say that victims want to be informed about errors and receive an apology promptly, but that only about one in three receive such redress. When an error results in what the commission calls “serious health consequences,” researchers found Oregonians were less likely to get an apology.
“The combination of transparency and apology after medical harm is what patients want and expect,” said TJ Sheehy, director of programs for the Oregon Patient Safety Commission, in a statement. “And while this can be challenging in practice, other studies show that providers do want to disclose when harm has occurred.”
State analysts acknowledged that it may be difficult to improve transparency on the issue, citing research that found more than 90% of surveyed physicians supporting disclosure after errors but not following through to do so. The recent Oregon-backed survey encourages health care organizations to adopt a communication and resolution program, a model of which is offered publicly by federal public health researchers.
The report also reiterated support for leveraging two existing commission programs, its Early Discussion and Resolution initiative and the Patient Safety Reporting Program. The former allows those close to individuals who experienced serious injuries or deaths to set up confidential meetings with providers for questions about what occurred during the incident outside of the formal legal system. The latter program allows Oregon health care facilities to voluntarily provide details about serious patient harm and strategies to avoid errors in the future.
“We can’t fix what we don’t know about. Real progress requires the courage to look hard at this data, listen to patients, and implement change at a systems level,” Valerie Harmon, the commission’s executive director, said in a statement.
“Medical harm isn’t unique to Oregon patients, but we are fortunate to have the tools to help support a better response for patients and their loved ones after harm occurs,” she added.
The patient safety commission conducted the review with support from Portland-based DHM Research, which has also provided insight into issues such as Oregon’s transportation, education and housing infrastructure. The study used a survey sample of more than 1,000 individuals.
