Reducing Medical Errors

Reducing one of the nation’s leading causes of injury and death—medical errors—will require rigorous changes throughout the health care system, including mandatory reporting requirements, according to the Institute of Medicine (IOM). An IOM report lays out a multifaceted strategy to reduce medical errors and calls on Congress to create a national patient safety center based at the Agency for Health Care Policy and Research (now the Agency for Health care Research and Quality).

The findings of one major study cited in the report suggest that medical errors kill some 44,000 people in US hospitals each year. Another study puts the number much higher, at 98,000. Deaths from medication errors in hospitals and other settings number more than 7000 annually.

“These stunningly high rates… are simply unacceptable in a medical system that promises first to ‘do no harm,” said William Richardson, chair of the committee that wrote the report and President and CEO of the W.K. Kellogg Foundation. The committee set as a minimum goal a 50% reduction in medical errors over the next five years.

“Our health care system is a decade or more behind other high-risk industries in its attention to ensuring basic safety,” Richardson said. “The risk of dying in a domestic airline flight or at the workplace has declined dramatically in recent decades, in part because of the creation of federal agencies that focus on safety. Drawing on that model, we urge Congress to create a center for patient safety within the US Department of Health and Human Services.

This center would set national safety goals, track progress in meeting them, and invest in research to learn more about preventing mistakes. It also would act as a clearinghouse—an objective source of the latest information on patient safety for the nation. For example, if a health care organization improves safety, its practices should be shared with a broad audience, and the center would help provide the needed channel to distribute that information.”

The majority of medical errors do not result from individual recklessness, according to the IOM report, but from basic flaws in the way the health system is organized. Medical knowledge and technology grow so rapidly that it is difficult for practi¬tioners to keep up. The health care system itself is evolving so quickly that coordination is often lacking.

The committee recommends establishing a nationwide, mandatory public reporting system. Hospitals first, and eventually other settings, would be responsible for reporting medical errors to state governments. Currently, about a third of the states have their own mandatory reporting requirements.

While the committee believes that the public has a right to know about errors resulting in serious harm, it recommends federal legislation to protect the confidentiality of data on medical mistakes that have no serious consequences. In such cases, information should be collected and analyzed solely for the purpose of improving safety and quality.

The report also recommends that licensing and certifying bodies implement periodic re-examinations of doctors, nurses, and other clinicians based on both competence and knowledge of safety practices. In addition, the Food and Drug Administration, which regulates prescription and over-the-counter drugs and medical devices, should increase its attention to public safety. Efforts should be made to eliminate similar-sounding drug names and labeling or packaging that foster mistakes. Health care organizations must create a “culture of safety,” designing systems geared to preventing and detecting hazards and minimizing the likelihood of error. Well-understood safety principles should be adopted, including standardizing and simplifying equipment, supplies, and processes and avoiding reliance on memory. All hospitals and health care organizations should implement proven medication safety practices, such as using automated drug-ordering systems.

The study was funded by the National Research Council and the Commonwealth Fund.