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Appendix 11 Reducing Medical Errors

A ttention to medical errors escalated over five years ago with the release of astudy from the Institute of Medicine (IOM), To Err is Human, which foundthat between 44,000 and 98,000 Americans die each year in U.S. hospitalsdue to preventable medical errors. Hospital errors rank between the fifth andeighth leading cause of death, killing more Americans than breast cancer, trafficaccidents, or AIDS. Serious medication errors occur in the cases of 5 to 10 per-cent of patients admitted to hospitals.

These numbers may understate theproblem because they do not include preventable deaths due to medical treat-ments outside of hospitals. Since the release of the IOM study, there has been greater focus on thequality of healthcare provided in the United States.

Quality experts agree thatone of the most common causes of errors is the medical system itself, not theindividuals functioning within the system.

Publication of the IOM report trig-gered substantial public and private sector activity, including the formation ofthe National Patient Safety Foundation by the American Medical Association,the creation of a non-punitive sentinel events reporting system by the JointCommission for the Accreditation of Healthcare Organizations, and the es-tablishment of new public private partnerships by the Veterans HealthAdministration and others.Still, experts agree that there is much more work to do.

For example,fewer than 3 percent of hospitals have implemented computerized drug or-dering systems, which one study found to reduce medication errors by 86 per-cent. In a December 2002 Kaiser Family Foundation survey, only 5 percentof physicians identified medical errors as a top healthcare concern.

Shortly af-ter the release of the 1999 IOM report, Congress gave $50 million to the U.S.Agency for Healthcare Research and Quality for research into the causes andprevention of medical errors. Beyond that, a flurry of legislative proposals inthe 106th and 107th Congress resulted in stalemate over issues such aswhether error reporting should be mandatory or voluntary and confidentialor publicly released.

Meanwhile, controversy over how to best address med-ical errors has entered into other debates, incuding whether the federal gov-ernment should restructure the current medical malpractice system. Stateshave also been a part of this debate, as several now have mandatory error re-porting rules and statutes with a patchwork of differing requirements.

As federal and state policymakers debate the issues related to reducingmedical errors, discussion will likely focus on several key issues, including:

• What kind of standardized national reporting of medical errors shouldbe established? Should it be voluntary or mandatory? Should it beconfidential or publicly reported? In which cases?

• What agency should be designated to receive error reports? What authority should the agency have to act on reports?

• What kind of reporting may or should be required for "near miss"events? What protections should be provided to reporters of errors andnear misses? What effect should this new reporting system have onexisting state reporting systems?

• Should Congress set national standards for mandatory overtime bynurses and limitations on work hours for medical interns and residents,both of which have been tied to increased medical errors?

• Should Congress mandate hospitals to install computerized drug orderentry systems and other technologies with proven ability to reduceerrors? If so, should the federal government provide financial support tosome or all hospitals to install these systems?

• Should the federal government set clear goals for the reduction oferrors over a period of years, particularly for Medicare and Medicaidpatients? Should penalties and/or incentives be created for providers toreduce errors?

• What steps can Congress and state legislatures take to alleviate a seriousnational shortage of nurses-because many medical errors have beenlinked with understaffing of nurses and use of temporary nurses?

• What is the role of regulatory agencies such as The Joint Commissionand the National Committee on Quality Assurance in national reformon medical errors?

• Should any reports submitted under a medical errors reporting systembe admissible as evidence in medical malpractice cases?