Patient safety now is the law of the land

JCAHO welcomes law on surging movement

The Joint Commission on Accreditation of Healthcare Organizations is hailing the passage of federal patient safety legislation that will encourage the voluntary reporting of medical errors, serious adverse events, and their underlying causes.

The Patient Safety and Quality Improvement Act of 2005 provides full federal privilege to patient safety information that is transmitted to a patient safety organization.

The Joint Commission expects to create or become part of a patient safety organization under the auspices of its new International Center for Patient Safety and seek federal approval under a new process to be created by the Department of Health.

Signed by President Bush July 29, the law is designed to promote cultures of safety across health care settings by establishing federal protections that encourage thorough, candid examinations of the causes of health care errors and the development of effective solutions to prevent their recurrence.

However, the Joint Commission warned that the American public should expect significant increases in the reporting of errors and their causes and the sharing of patient safety solutions.

The Joint Commission, which accredits more than 15,000 health care organizations, will be in a unique position to gauge the actual impacts of the new legislation by virtue of its continuing on-site reviews of these organizations.

In particular, it will become readily apparent as to whether health care organizations have truly adopted cultures of safety that constructively encourage medical error and adverse event identification and reporting and the development of appropriate internal solutions.

The Joint Commission maintains one of the nation’s most comprehensive voluntary reporting systems for serious adverse health care events and their underlying causes. For example, infection control professionals are instructed to perform a root-cause analysis for cases of unexpected death due to health care-associated infections.

The underlying causes of adverse events that have been reported to the Joint Commission are fed back to the health care community to identify potential patient safety dangers and provide recommendations regarding preventive solutions. However, the number of adverse event reports submitted to the Joint Commission each year represents a small fraction of the actual number of adverse events that experts estimate occur annually.

Previously, evaluative information about the underlying causes of adverse events was not always considered confidential or protected from lawsuits, a fact that the Institute of Medicine has blamed for driving errors underground and slowing progress in improving patient safety.

"This bill is a breakthrough in the blame-and-punishment culture that has literally held a death grip on health care," Dennis S. O’Leary, MD, president of the Joint Commission said in a statement.

"When caregivers feel safe to report errors, patients will be safer because we can learn from these events and put proven solutions into place," he added.