A look at the College's response to the IOM report on medical errors
By Robert B. Doherty
Politicians in Washington are known for having an exaggerated sense of their own importance. Lawmakers rarely deal with life-and-death issues, but that doesn't stop them from engaging in overstated rhetoric on even the most trivial of policy issues.
Occasionally, though, an issue arises that deserves such attention. The subject of the recent Institute of Medicine (IOM) report, "To Err is Human: Building a Safer Health System," is one such issue.
When the IOM reported that between 44,000 and 98,000 Americans die each year as the result of preventable medical errors, the reaction among politicians was as swift as it was predictable. Lawmakers expressed grave concern about the "crisis" and promised swift hearings—and legislation—to fix the problem.
The College supports mandatory reporting requirements, but not for "near misses" and system errors that don't seriously injure patients.
For an organization like ACPASIM, whose mission is "to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine," the IOM report poses a unique challenge. While the risk to patients of preventable errors is real, so is the danger that Congress will enact punitive measures that will do more harm than good. ACPASIM's challenge is to convey to Congress not only what it should do to facilitate improvements in patient safety, but also what it should not do.
ACPASIM's initial response
The IOM released its report on Dec. 7, 1999. Over the following six weeks, the College's Health and Public Policy Committee worked feverishly to develop a response for the Board of Regents to consider at its January meeting. The HPPC and Regents decided to focus the College's initial response on three central issues:
- Should ACPASIM challenge the IOM's estimates of probable deaths from medical errors?
- Should the College support the creation of a center for patient safety within the federal government, or should it advocate a strictly voluntary response by the private sector?
- Should ACPASIM support or oppose mandatory reporting of medical errors? Should the College advocate legislation to facilitate voluntary reporting of systemic issues that may lead to preventable errors?
The College concurs with many of the IOM report's findings. For example, we agree that too many Americans are dying from or being injured by preventable errors. We concur that reducing those errors will require a sustained commitment from health care professionals and other industry "stakeholders." And we agree that the federal government should have a major role in facilitating improvements.
While we do not completely agree with the IOM's estimates of preventable deaths, we decided not to challenge the numbers. Arguing, for instance, that the number of lives lost to errors is "only" 10,000 or 20,000 each year, instead of the more than 40,000 estimated by the IOM, would be viewed as avoiding—rather than accepting—the need for improvement. For patients, even a single death from a preventable error is one too many.
The College decided to support the creation of a center for patient safety within the Agency for Healthcare Research and Quality (AHRQ), formerly known as the Agency for Health Care Policy and Research. As envisioned by the IOM and ACPASIM, such a center would have a strictly non-regulatory role. It would set national goals for patient safety and track progress in meeting those goals.
AHRQ is unique within the federal government because it has the expertise and infrastructure to fund research and coordinate activities concerning health care quality. Under the direction of John M. Eisenberg, MACP, a former College Regent, AHRQ is more likely than most federal agencies to recognize that its role should be to support—rather than attempt to usurp or dictate—quality improvement in the private sector.
The IOM also proposed establishing a nationwide mandatory reporting system that would collect information through state governments about "adverse events that result in death or serious harm." Initially, mandatory reporting would apply to hospitals, but it would later be extended to other settings. The IOM report also proposed developing standards on what should be reported and to whom.
ACPASIM decided to support mandatory reporting of major incidences that cause death or serious injury to the patient. We believe strongly, however, that mandatory reporting should apply only to major incidences, as the IOM intended. The College will oppose efforts to broaden mandatory reporting requirements to include so-called "near misses" and other system errors that do not cause death or serious injuries. Furthermore, ACPASIM agrees with the IOM that only after careful analysis should a subset of reports attributable to error be identified for follow-up action and report to the public. We do not believe that all data should be released to the public.
The College strongly concurs with the IOM's belief that voluntary reporting of errors that cause minimal or no harm should be encouraged. For voluntary reporting to have the cooperation of health professionals, however, strict confidentiality protections are imperative. ACPASIM will lobby Congress to enact legislation to protect voluntary reporting systems from legal discovery and to extend peer review protections to data related to patient safety, as recommended by the IOM.
By confronting, rather than avoiding, the challenges raised by the IOM report, the College is earning the credibility needed to steer the debate in Washington toward constructive approaches rather than punitive measures.
ACPASIM recognizes, however, that the IOM raises important questions that demand more extensive analysis than was possible in the College's preliminary response. For example, how will "major errors" be distinguished from "minor" ones? To whom should data be reported? What happens when the information is reported? What data will be released to the public and in what form? What do we know about "best practices" to prevent avoidable errors? Should re-licensure of physicians be mandated?
The College has agreed to accept the IOM's charge to "make a visible commitment to patient safety" within our organization. Doing so will involve not only the committees and staff responsible for public policy, but also those involved in education, scientific policy and communication. Over the next several months, ACPASIM will be examining what steps we should take to show a commitment to patient safety in all of the College's endeavors.
Patient safety is not one of those issues that will stir up a tempest in Washington and then blow over. It will be on the agenda of Congress—and ACPASIM—for years to come. The serious attention being paid to the issue is justified. Like war and airplane crashes, patient safety is one of those few issues being discussed in Washington that truly is a matter of life and death.
Robert B. Doherty is ACPASIM's Senior Vice President for Governmental Affairs and Public Policy.
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