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Lawmakers urged to agree on medical error fixes

By Todd Zwillich

Last Updated: 2003-06-12 9:51:38 -0400 (Reuters Health)

WASHINGTON (Reuters Health) - Patient safety experts urged Congress to break an impasse over medical errors legislation Wednesday, saying that federal action was essential to forming a "culture of quality" at U.S. hospitals.

A bill creating a new system of non-profit "patient safety organizations" to collect anonymous reports of hospital errors or "near-misses" overwhelmingly passed the U.S. House in March. But the measure has since stalled in the Senate because of disagreements over whether such reports should be available to the public or should be immune from lawsuits.

Leaders from national patient safety groups pled with lawmakers to find agreement on the bill. They warned that U.S. hospitals have balked at substantially improving patient safety systems over the last few years.

A 1999 report from the federally funded Institute of Medicine estimated that 44,000 to 98,000 Americans die in hospitals each year because of preventable medical errors. The report spurred Congress and several private groups to begin efforts to enhance safety practices at health care institutions.

"We have a very big problem and we have not gotten on top of it yet," said Dr. Dennis S. O'Leary, president of the Joint Commission on Accreditation of Healthcare Organizations, a non-profit hospital-credentialing body.

"The passage of patient safety legislation must become an urgent priority of this Congress," he said.

Experts told lawmakers that many physicians, nurses and hospital executives have avoided implementing quality initiatives for fear that reports of preventable errors could be used against them.

Many experts are waiting for guidance from Congress, they said. The bill passed by the House in March calls for voluntary reporting of medical mistakes to patient safety organizations and then encourages the groups to report back to hospitals on how to avoid the errors in the future.

"It has to not be viewed as a punitive system. It has to be viewed as a fair system," Dr. James P. Bagian, director of the federal National Center for Patient Safety, told members of a Senate investigations subcommittee.

"I call 'fault' the f-word in medicine," he said.

O'Leary urged the senators to consider changing federal Medicare and Medicaid laws to provide financial incentives for hospitals that show tangible reductions in the frequency of dangerous errors.

Others urged that health workers voluntarily reporting mistakes should have federal protections against getting sued based on the reports.

Roxanne Goeltz, an air traffic controller from Burnsville, Minn., whose brother Mark died mysteriously in a hospital in 1999, told lawmakers that U.S. hospitals should strive to be more like the aviation system when it comes to dealing with errors.

Federal air-accident investigations are rarely based on assigning blame, but are instead based on finding root causes for failures and then implementing procedural changes, she said.

"Blaming individuals does not get us anywhere. It's what we've been doing in health care for years," Goeltz said.

Copyright 2002 Reuters.