February 2000 Bulletin

IOM urges U.S. public safety center

AAOS shows how medicine can tackle preventable system errors

Who should take the lead on eliminating preventable medical errors, physicians or the government?

The issue is coming to a head as the political community responds to the Institute of Medicine’s (IOM) report on medical errors which recommended establishing a new Center for Patient Safety in the Agency for Healthcare Research and Quality, and voluntary and mandatory reporting of medical errors.

Recognizing the problem of medical errors has long been studied and discussed, the IOM report in December was a call to end a "cycle of inaction." The estimate that up to 98,000 people die each year from medical errors and that preventable errors cost as much as $29 billion, galvanized the political community into action.

President Clinton held a Rose Garden press conference to announce a series of initiatives involving health plans for federal employees; Sen. Edward Kennedy (D-Mass.) said he will introduce the Error Reduction and Improvement of Patient Safety Act; the Senate subcommittee on labor, health and human services and education held a hearing; and a national conference with state health officials to promote best practices in preventing medical errors is scheduled for March.

Experts who have studied the problem of medical errors—the majority of which are preventable system errors—have identified equipment failures, misread lab reports, mismatching of blood during transfusions, misread prescriptions and wrong-site surgery, among others.

The Academy has demonstrated how a medical society can tackle preventable systems problems.

In 1997, the Academy board of directors took a bold stand in officially recognizing that wrong-site surgery is preventable and adopted an Advisory Statement that encourages orthopaedic surgeons to mark the operative site with their initials. In 1998, the Academy took a leadership position among surgical specialties and launched the Sign Your Site program, calling for a national effort among surgeons, hospitals and other health care providers to initiate preoperative and other institutional regulations to eliminate wrong-site surgery in the United States.

The Academy’s professional liability committee has tackled the medical errors problem from another direction with the publication in 1996 of "Managing Orthopaedic Malpractice Risk." By identifying the factors that often cause a patient to file a malpractice lawsuit, the committee also is instructing orthopaedic surgeons how to prevent medical errors. A revised edition is being readied for publication by the Academy’s Annual Meeting in March.

The medical community, in general, is supportive of the IOM goal to improve patient safety by preventing system errors. But the IOM recommendations also raise fears of federal intervention and public disclosure of errors.

The IOM recommends that Congress should create a Center for Patient Safety within a federal agency to set national goals for patient safety, define prototype safety systems and develop and disseminate tools for identifying and analyzing errors.

James Heckman, MD, 1998 Academy president, says, "a national center to study the problem and identify systems errors that can be corrected, like our Sign Your Site program, would be valuable." Robert D. Ambrosia, MD, Academy president, and S. Terry Canale, MD, first vice president, agree.

But they, like many others in the medical community, oppose the IOM recommendation for a nationwide, mandatory reporting system that makes the errors known to the public.

The IOM recommends voluntary reporting which protects confidentiality for what are described as "near misses or lesser injuries," and mandatory reporting of "serious preventable adverse events" which allows public disclosure. The mandatory reporting initially would be required of hospitals and eventually of other institutional and ambulatory care delivery settings.

"Public reporting alone would be useless, except to malpractice attorneys," says Dr. Heckman. Dr. Canale is concerned that reporting will lead to disciplining people. He believes "physicians should police physicians."

"It would be best if medicine and not government was in control of this process," says Edward Toriello, MD, chairman, board of councilors. "With proper safeguards for confidentiality, I’m certain that problems can be identified and strategies can be implemented by specialty societies that will reduce the number of errors that lead to patient harm."

John Eisenberg, MD, director for the Agency for Healthcare Research and Quality, told the Senate subcommittee hearing that "..our approach to medical mistakes needs to change from the mode of "name you, blame you, shame you" to sharing information so that an error is not repeated. Like the patients that they care for, health care professionals are human, and humans are not perfect—this is something we cannot change. However, we can change the system in which providers care for patients. Research has shown that system improvements can reduce the error rate and improve the quality of care."

The AMA opposes the mandatory reporting system, saying doctors will continue to make mistakes in secret if they fear discussing them can lead to punishment or lawsuits. Nancy Dickey, MD, former AMA president, told the Senate subcommittee hearing that the AMA is "concerned that consumers see data on mistakes; they [the errors] must be put in context." Sen. Arlen Spector, (R-Pa.) responded that, "it will be difficult to inform consumers without opening Pandora’s box, but we will be pursuing it."

The IOM’s proposals on medical errors are not new, says Steven Fountain, MD, chairman of the Academy’s professional liability committee. He points out that "the National Patient Safety Foundation has been working on this for three years. The beauty of the [IOM] report is that it raises the profile of systems errors and may lead to ways to try to correct them."

But Dr. Fountain is worried that "the federal government will fund the effort with a fair amount of money and ...it will become a political ball." He’s also concerned that there will be "individual blame rather than systems blame."

Dr. Fountain warns that the effort to reduce medical errors could increase the adversarial relations of physicians and hospitals. "If it is not handled appropriately, there could be a lot of finger pointing of blame for the problem," says Dr. Fountain.

Improving the physician-patient relationship through shared decision-making responsibilities—patient empowerment—also would help reduce errors, says Dr. D’Ambrosia. See the Across the President’s Desk column.

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