EyeWitness Summer 2010 - 21

Create accountability through transparency. In the original report, the IOM recommended two national reporting systems for medical errors: one voluntary that would be confidential to help health care providers learn from mistakes and another mandatory that would make mistakes public. Progress has been made mainly with the voluntary system, says McGiffert. ‘’The public has not been given the information to know whether we are safer now than we were then,” she says. She notes that 24 states don’t have any medical error reporting systems in place; most that do don’t publicize facility-specific information to the public. Measure the problem. In the original report, the IOM called for a Center for Patient Safety to be set up within the federal Agency for Healthcare Research and Quality (AHRQ). But while the AHRQ is trying to do this, the efforts are hampered by the lack of reliable reporting of medical errors, according to the report. In its most recent report, issued this month, the AHRQ reported that patient safety declined by about 1% a year in the six years after the 1999 report. Raise standards for competency in patient safety. The IOM called for periodic tests of doctors’ and nurses’ competence and knowledge of safety practices. Many such campaigns have been launched in the private sector, McGiffert says, but the results remain fragmented, with no process to measure improvement on a national basis. “Certainly there has been a lot of work done,” McGiffert tells WebMD. “But we don’t know if it’s done any good. We have no real evidence we are better off than we were 10 years ago. There is no disclosure of information. There is very little information to grab onto.” On a positive note: “We have worked for hospital disclosure of infection rates,” she says. “Twenty six states now have laws requiring it, and eight have actually put out reports.” What’s needed, she says, is a national system, run by an independent entity, to track progress on health care safety.

“We have done more in America than any other country in the world to increase patient safety,” he says. But it’s been done at the ground level, by individual doctors, nurses and hospitals, he says.

Where Errors Occur
Errors occur not only in hospitals but in other health care settings, such as physicians’ offices, nursing homes, pharmacies, urgent care centers, and care delivered in the home. Unfortunately, very little data exist on the extent of the problem outside of hospitals. The IOM report indicated, however, that many errors are likely to occur outside the hospital. For example, in a recent investigation of pharmacists, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled improperly each year in the State.

Costs
Medical errors carry a high financial cost. The IOM report estimates that medical errors cost the Nation approximately $37.6 billion each year; about $17 billion of those costs are associated with preventable errors. About half of the expenditures for preventable medical errors are for direct health care costs.

Not a New Issue
The serious problem of medical errors is not new, but in the past, the problem has not gotten the attention it deserved. A body of research describing the problem of medical errors began to emerge in the early 1990s with landmark research conducted by Lucian Leape, M.D., and David Bates, M.D., and supported by the Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality (AHRQ). The final report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, released in 1998, identified medical errors as one of the four major challenges facing the Nation in improving health care quality. Based on the recommendations of that report, President Clinton directed the establishment of the Quality Interagency Coordination Task Force (QuIC) to coordinate quality improvement activities in Federal health care programs. The QuIC includes: the Departments of Health and Human Services, Labor, Veterans Affairs, Commerce, and Defense; the Coast Guard; the Bureau of Prisons; and the Office of Personnel Management.

Medical Errors: “Failure”
The new report is “right on,” says Lucian Leape, MD, adjunct professor of health policy at Harvard School of Public Health and longtime patient safety advocate. The lack of progress in implementing the IOM recommendations, he says, ‘’is an immense public policy failure.” “It’s hard to argue with the fact that we’re not where we need to be,’’ agrees Diane Pinakiewicz, president of the National Patient Safety Foundation. Even so, some progress is evident, Leape tells WebMD. “There have been improvements on the hospital level with very little help from the government,” he says. He is referring to the common hospital protocols to be sure the right patient is operated on, the right side or limb is operated on, and it’s the right operation.
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Public Fears
While there has been no unified effort to address the problem of medical errors and patient safety, awareness of the issue has been growing. Americans have a very real fear of medical errors. According to a national poll conducted by the National Patient Safety Foundation:
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EyeWitness Summer 2010

Table of Contents for the Digital Edition of EyeWitness Summer 2010