IOM report on medical errors: A wake-up call?
IOM report on medical errors: A wake-up call?
A recent Institute of Medicine (IOM) report on the high number of deaths caused by medical errors seems to have been not only a wake-up call to health care professionals but to those involved in formulating state policy.
"States are important levers of change," Trish Riley, executive director of the National Academy for State Health Policy (NASHP) in Portland, ME, said at the group’s 13th annual conference in Bloomington, MN, in August. "It’s tough to keep public attention on this. . . . The public doesn’t fully understand this issue."
But to solve the problem, that’s exactly what states must do, she added. Keeping the issue public brings more awareness to the problem, Ms. Riley said, because until the public understands the deadly reach of medical errors into their own lives, the problem will persist.
The IOM report stated that medical errors lead to between 44,000 and 98,000 patient deaths annually, making it the eighth leading cause of death in the United States. The annual costs of those errors is estimated to be as much as $29 billion. Even using the 44,000 figure, that is more deaths from medical mistakes annually than from highway accidents, breast cancer, or AIDS, the report said.
Ms. Riley said oversight for hospitals must increase in order for medical errors to decline. Fifteen states, she said, have introduced 45 bills since December regarding oversight, and that’s a step in the right direction.
"Fifteen states have mandatory reporting of adverse events," she said. "But there is no common definition of adverse events or medical errors."
Because of the lack of definition for adverse events or medical errors, it is hard to craft legislation to fight them, Ms. Riley explained. The IOM report defined "error" as the "failure to complete a planned action as intended or the use of a wrong plan to achieve an aim. Not all errors result in harm, and the report recommended that a nationwide, mandatory public reporting system be instituted.
"Hospitals first, and eventually other places where patients get care, would be responsible for reporting such events to state governments," the IOM recommended.
Joyce Greenleaf, assistant regional inspector general, Office of the Inspector General, in Boston, told conference attendees that states must make sure that minimum standards are met to prevent errors. Accreditation is important, she said, but states should be able to respond more from the front lines of hospital health care and make hospitals more publicly accountable.
"The downside for states is that they lack a routine presence in hospitals because they lack resources and tend to be more reactive than preventive," she said. "It is in the best interest of states to take advantage of their own strengths and of the Joint Commission [on Accreditation of Healthcare Organizations]. There should be state initiatives and public disclosure on the Internet, using surveys and performance measures. States can complement other systems of oversight, so states should play to their strengths."
Nancy Foster, coordinator of policy initiatives for the Agency for Healthcare Research and Quality in Rockville, MD, suggested to NASHP members that a plan should be created for reducing medical errors by 50% in the next five years. Parts of her plan include conducting research into reducing medical errors, converting findings into improved practices, and educating the public about safety issues. Reporting systems are also part of her vision. She recommended that mandatory reporting systems be put in place in all states in three years, with no identification of patients or health care professionals. The voluntary systems she recommended include public and private systems that also keep tabs of errors that cause minimal harm and close calls, and that all data be kept confidential.
Ms. Foster also recommended integrating all data from federal, state, and private systems to develop a response system and common approaches to privacy and peer review protections, and that all participate in a national quality forum. Reporting all errors, from minor to major, is one of her goals. "Only some events end up with adverse consequences," she said. "If a nurse takes the wrong bottle off a shelf, realizes the error, but the patient doesn’t get the medicine, an error has still been made," she said. "We need to establish a sense of urgency that change needs to be made."
That sentiment was echoed at the meeting by Janet Corrigan, director of the Quality of Care in America Project from the IOM. "States must keep the pressure on and the issue visible. Because once the issue passes from the media and we move on to the next issue du jour, medical errors are easy for the public to forget."
Seven bills have been enacted recently in five states regarding medical errors. In Florida, the Florida Commission on Excellence in Health Care was created to improve health care through better reporting standards, data collection and review, and quality measurements. And in Washington, the Department of Public Health must now publicly disclose information received through filed reports and inspections, and hospitals must have quality assurance programs with access to records by the state.
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