O’Leary calls for more info on medical errors

Declaring that the solution to reducing medical errors rests with the free exchange of information about serious adverse events, the president of the Joint Commission on Accredita tion of Healthcare Organizations recently warned congressional investigators that patient safety will not be improved until Congress passes federal protections to encourage the sharing and use of this information.

Dennis O’Leary told three House subcommittees at a hearing on "Medical Errors: Improving Quality of Care and Consumer Information" that the Congress can have an immediate and dramatic effect in making health care safer.

"Fear of reprisals, public castigation, and loss of business continue to impede both reporting and the production of in-depth analyses of the root causes underlying medical errors. Rather than surfacing errors, our blame-and-punishment-oriented society drives them underground. Congress can make a critical contribution to solving this problem by passing legislation to address these legitimate fears," O’Leary said.

His remarks came before hearings conducted by the Committee on Commerce’s Subcommittee on Health and Environment and its Subcommittee on Oversight and Investigations, and by the Commit tee on Veterans’ Affairs’ Subcommittee on Health.

"We believe that the solution to reducing the number of medical errors resides in developing effective mechanisms for collecting, analyzing, and applying existing information," he said.

O’Leary noted that the Joint Commission’s efforts to track sentinel events and other medical errors has been severely constrained by the lack of statutory protections for the analysis of those events and the sharing of the findings with responsible quality oversight bodies. The Joint Commission’s sentinel event program contains the necessary elements for success, he said, but it demonstrates very clearly that no reporting system for serious errors can fulfill its objectives without congressional help.

O’Leary suggested that policy-makers view the Joint Commission’s sentinel event program as a "treasure trove of lessons learned" in designing any new program to promote error reduction. Specifically, he recommended that these elements must be part of any effective medical error report ing program:

Pragmatic and standardized definition of reportable medical errors. Establishing uniform definitions is crucial in the effort to analyze and monitor errors. The Joint Commission further urges that any mandatory reporting system focus on the most serious adverse events.

Requirement for in-depth analyses of medical errors. An intensive analysis of the causes underlying any serious error must be conducted to fully understand and prevent future adverse events. Those analyses should focus on systems and processes rather than individual performance, O’Leary said. A reporting system that stops with the report of the error itself is not a credible program and will not lead to future error prevention, he said.

Creation of a protected environment for reporting and responding to errors. Federal legislative protection is necessary to ensure that information developed in response to a medical error — and shared with an accreditor or other reporting system — will be provided clear protections from disclosure. Without this protection, neither mandatory nor voluntary reporting programs will achieve their error-reduction goals.

Sharing of error-related information with quality oversight bodies having a legitimate "need to know." Accrediting bodies, responsible government agencies, and other quality oversight entities must have full access to any error-related databases.

Dissemination of lessons learned and best practices. To measurably improve patient safety, information gleaned from the analysis of serious adverse events must be widely disseminated throughout the health care community.