We all make mistakes. But when it comes to medical errors, mistakes are a very serious matter. Some estimates place medical errors as the nation’s 8th leading cause of death. Some 44,000 to 98,000 Americans die each year as a result of medical mistakes, according to a 1999 Institute of Medicine report. But hope may be near for a decline in medical errors should legislation become law by gaining the Senate approval that is pending as of this writing.

The Patient Safety and Quality Improvement Act, which overwhelmingly passed the House (418-6) in mid-March, defines a new voluntary medical error reporting system. The medical errors tracking system would provide for the Secretary of Health and Human Services to certify a number of private and public organizations to act as patient safety organizations. These organizations would collect and analyze anonymous data on medical errors, determine their causes, and develop and disseminate evidence-based information (a National Patient Safety Database) to providers to help prevent similar problems in the future. Participation would be voluntary, and all information would be kept confidential. Fines for disclosure of information could run as high as $20,000.

The Act would provide peer review protections for documents and communications that providers submit to patient safety organizations. The information in the Act — any “information, report, memorandum, analysis, deliberate work, statement or root cause analysis” — would be protected from civil or administrative subpoenas or orders, discovery process, disclosure under the Freedom of Information Act, disclosure as evidence in state or federal civil or administrative proceedings or use by an accrediting organization.

Proponents agree that the Act would remove the threat of blame from voluntary disclosure, and encourage providers to gather and analyze data about the causes of medical mishaps and then share best practice findings with others. JCAHO has been publicly advocating this for some time.

Interestingly, in a survey of 2,000 physicians and 500 citizens reported in October in the Archives of Internal Medicine, 60 percent of the citizens believed a national agency was needed to deal with the problem of medical errors while only 24 percent of physicians agreed. Yet, 93 percent of physicians thought more training was necessary in how to deal with medical errors.

The pending legislation also includes grants of $50 million (in FY2004 and FY2005) to hospitals or other healthcare providers for computer upgrades to improve patient safety and healthcare quality and reduce adverse events and complications from medication errors. The HHS Secretary would be required to “develop or adopt voluntary national standards promoting the interoperability of IT systems involved with healthcare delivery.”

Make no mistake, there will be a lot of healthcare eyes on H.R. 663. And what is still the single most important means of protecting the health of patients? Hand washing.

Mary C. Tierney, Editor
mtierney@mwc.com