September 8, 2004

Back in 1999, the National Academy of Sciences' Institute of Medicine (IOM) issued a report that shocked Americans from sea to shining sea. The report claimed that between 44,000 and 98,000 people die each year because of mistakes in U.S. hospitals.

Then, this summer, a new report using “patient safety indicators” developed by the Agency for Healthcare Research and Quality estimated that between 2000 and 2002, an average of 195,000 hospital patients died every year from preventable errors.

Both reports set off stormy debates with some claiming that the death rates were “underestimated,” while others insisted that the estimates were “grossly exaggerated,” were based on misleading statistical extrapolations, and had no scientific basis.

In our opinion, America 's system of medicine is overwhelmingly safe, particularly when one considers that there are millions of hospital caregiver/patient interactions every day. Hospital care is “people taking care of people,” and as long as we have human beings doing that, the potential for errors is going to be there despite newly installed “solutions” like computerized physician order entry systems and electronic medical records.

But, medical errors are never excusable. Any error that harms a patient is one error too many. That's why hospitals are stepping up to demonstrate the leadership, innovation, and commitment necessary to improve care and patient safety. These hospitals are moving to a culture of safety where everyone within the organization feels free to report and discuss actual and potential errors and believes that improving patient safety is their responsibility.

The greatest impediment to reporting errors is that we punish people for making mistakes. Anything we can do to move hospitals closer to a blame-free, non-punitive environment should be encouraged. That's why we've been urging Congress for more than a year to help us foster this environment. Our efforts are beginning to pay off.

The Senate recently passed the Patient Safety and Quality Improvement Act, legislation that can help hospitals achieve a culture of safety. The House cleared similar legislation in March 2003. Now, we must push the Congress to reconcile the differences between the two bills and approve the final measure as quickly as possible. Then, President Bush must sign the legislation without pause.

This legislation is important because it follows the recommendations of the IOM's 1999 report, “To Err is Human.” That report called for a system of voluntary confidential error reporting so that deeper systemic weaknesses in care can be analyzed instead of blaming individuals for unintentional errors.

Both the Senate and House bills create patient safety organizations (PSOs) that would collect confidential data on medical events from hospitals, doctors, and other providers. The reports could not be used as evidence in lawsuits. Only health professionals would see the reports so they could learn what can go wrong, why, and how to fix it to prevent future harm.

The patient safety legislation approved by Congress is modeled on the reporting system developed nearly 30 years ago by the aviation industry. It enables pilots, flight attendants, and others in the civilian aviation industry to report unintentional errors on a strictly confidential non-punitive basis. More than 300,000 incidents have been reported to date, and the system is credited with dramatically improving aviation safety.

If we can adopt the same approach in hospitals, changes that can make patient care safer and better will occur more quickly.