IOM calls for major effort to reduce medical errors

Reducing the unacceptably high rate of medical errors will require major changes throughout the health care industry, including mandatory reporting requirements, according to a new report from the Institute of Medicine (IOM) of the National Academy of Sciences in Washington, DC. The report lays out a comprehensive strategy for government, industry, consumers, and health care providers to reduce medical errors, and it calls on Congress to create a national patient safety center to develop new tools and systems needed to address persistent problems.

The report recommends a four-part plan designed to create both financial and regulatory incentives that will lead to a safer health care industry. The major component of the plan is a new federal agency devoted to medical safety.

The IOM said health care is a "decade or more" behind other high-risk industries in addressing consumer safety, and it suggested using the successful federal regulation of the airline industry as a model for a new medical safety agency.

"Using that model, Congress should create a center for patient safety within the U.S. Depart ment of Health and Human Services [HHS]," the committee says. "This center would set national safety goals, track progress in meeting them, and invest in research to learn more about preventing mistakes."

Mandatory reporting proposed

The center is proposed as part of the HHS Agency for Health Care Policy and Research; Congress would need to spend $30 million to $35 million to set it up, the committee says. That estimate is based on the kind of work the center would perform and on investments in issues of similar magnitude, as well as safety research by the public and private sectors. Funding would need to grow to at least $100 million, a little more than 1% of the $8.8 billion spent each year as a result of medical errors that cause serious harm.

The committee defines "error" as the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim, and notes that not all errors result in harm. To learn about medical treatments that lead to serious injury or death and to prevent future occurrences, the committee recommends establishing a nationwide mandatory public reporting system. Hospitals first, and eventually other places where patients get care, would be responsible for reporting such events to state governments. Currently, about a third of the states have their own mandatory reporting requirements.

Copies of the report, "To Err Is Human: Build ing a Safer Health System" are available by calling (202) 334-3313 or (800) 624-6242. The cost of the report is $45 (prepaid) plus shipping charges of $4.50 for the first copy and $.95 for each additional copy.