JCAHO urges passage of patient safety regs

Law to ensure confidential reporting of errors

National patient safety legislation that would encourage the confidential reporting of medical errors is critically needed in today’s health care system, urged Dennis O’Leary, MD, president of the Joint Commission.

"Thousands and thousands of errors remain hidden today, and each of those is a lost opportunity for education and change," O’Leary said in recent testimony before Congress. "Federal confidentiality protections for reported adverse events, near misses, and their underlying causes are inextricably linked to the efforts to create cultures of safety inside health care organizations."

Such protective legislation would allow sharing of information and mutual problem-solving, he said.

The House recently passed H.R.663, the Patient Safety and Quality Improvement Act. The bill awaits consideration by the Senate.

"We are very hopeful that this is the year in which this critical piece of legislation will actually be enacted," O’Leary testified June 11, 2003, before the Senate Committee on Governmental Affairs.

If approved, the legislation will prevent subpoena of error-related information from health care organizations and practitioners, shielding providers from liability so medical errors can be analyzed and reduced throughout the medical system.

"[This bill] contains explicit language to clearly preserve that protection when the information is shared with an accrediting body for purposes of improving patient safety and health care quality," he said.

That could mean, for example, infection control professionals could report fatal or life-impairing nosocomial infections to the Joint Commission without fear of institutional liability. The Joint Commission makes considerable efforts to protect the confidentiality of its Sentinel Event Database, but many feel that only federal legislation can provide the protection to open up a national discussion of medical errors.

O’Leary also suggested that lawmakers establish performance incentives for achieving safety objectives through adoption of the Joint Commission’s annual national patient safety goals.