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Group Asking U.S. for New Vigilance in Patient Safety
November 30, 1999
WASHINGTON -- Citing evidence that medical errors cause tens of thousands of deaths each year, the National Academy of Sciences called Monday for a new federal agency to protect patients and said Congress should require all health care providers to report mistakes that cause serious injury or death.
In a report, the academy's Institute of Medicine said that "health care is a decade or more behind other high-risk industries in its attention to ensuring basic safety."
In hospitals alone, the report said, research suggests that medical errors kill 44,000 to 98,000 people a year, compared with the toll from highway accidents, about 43,450, breast cancer, 42,300, or AIDS, 16,500.
The chairman of the panel that conducted the study, William C. Richardson, said, "These stunningly high rates of medical errors -- resulting in deaths, permanent disability and unnecessary suffering -- are simply unacceptable in a medical system that promises first to 'do no harm'. "Richardson is president of the W. K. Kellogg Foundation in Battle Creek, Mich., which has financed many health care projects for low-income people.
The panel said safety experts could prevent many of the injuries and deaths if they systematically collected and analyzed data on medical errors, to identify the causes. Accordingly, the panel said, the United States should strive, as a "minimum goal," to reduce medical errors by 50 percent in the next five years.
"To err is human, but errors can be prevented," the report concluded. "
The new study was initiated by the academy because of growing evidence, and a growing perception among experts, that the quality of medical care falls far short of what it could be. The study, unlike many projects of the academy, was not commissioned by Congress or by any government agency.
The report said the proposed Center for Patient Safety could learn some lessons from other government agencies like the Federal Aviation Administration and the Occupational Safety and Health Administration. The chance of dying in a domestic airline flight or at the workplace has declined sharply in recent decades, in part because of the efforts of these agencies, the panel said.
In another significant recommendation, the study said Congress should require health care providers to inform state governments of any medical errors that cause serious harm to patients. The requirement would apply first to hospitals, then to doctors, clinics, outpatient surgery centers, nursing homes and others that care for patients.
Currently, the panel said, 20 states, including New York, New Jersey, Connecticut and California, have some reporting requirements. But Janet M. Corrigan, the director of the study, said, "Many states don't have any mandatory reporting."
Monday's report condemns the current system of handling medical mistakes, which relies on a combination of peer review, federal and state regulation, malpractice lawsuits and evaluations by private accrediting bodies. "There is no cohesive effort to improve safety in health care," the panel said.
The panel said reports on medical errors that cause serious harm to patients should be available to the public. Ms. Corrigan acknowledged that such information might be used against doctors and hospitals in lawsuits by injured patients or their survivors. "That's certainly possible with a mandatory reporting system," she said.
From the reports filed with state agencies, Ms. Corrigan said, consumers could identify hospitals where patients have been injured as a result of medical errors. But she said the panel had not specified whether the names of individual doctors should be disclosed.
While the public has a right to know about errors causing serious harm, the panel said, Congress should protect the confidentiality of information about less serious mistakes. This, it said, would encourage doctors and hospitals to report such incidents voluntarily.
Richard H. Wade, senior vice president of the American Hospital Association, said: "Every hospital in America is working to reduce medical errors. We agree that the nation needs a better system of reporting and tracking these errors, but a new federal agency may not be the answer. Mandatory reporting can be useful, but it must not become punitive. People will be reluctant to report mistakes if they're afraid of being punished."
Dr. Nancy W. Dickey, a former president of the American Medical Association, said, "Any error that causes harm to a patient is one error too many."
But Dr. Dickey expressed concern about mandatory reporting and public disclosure of serious errors. "On the surface," she said, "it appears to be a relatively straightforward step, but actually it engenders all sorts of problems with confidentiality and liability. Doctors find themselves in a real bind. We understand the importance of investigating errors early on, while everybody has a fresh memory. But there are still insurance companies that would advise a physician not to tell anybody."
In its report, the National Academy of Sciences said federal and state government agencies should pay more attention to the safety of patients when they license, evaluate and regulate health care providers.
It said state licensing boards should periodically re-examine doctors and nurses to check their competence and knowledge of safety practices.
More than 7,000 Americans die each year as a result of "medication errors," which include the prescribing or dispensing of the wrong drugs, the panel said. By contrast, it said, about 6,000 Americans die each year from workplace injuries.
"In terms of lives lost," the panel said, "patient safety is as important as worker safety."
Most medical errors, it said, result not from individual recklessness, but from basic flaws in the way hospitals, clinics and pharmacies operate.
For example, it said, pharmacists often have difficulty deciphering the writing of doctors who prescribe drugs. Many drug names sound alike, causing confusion for doctors, nurses and patients. And in a fragmented health care system, doctors often do not have complete information about treatments prescribed for their patients by other physicians.
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