IOM calls on Congress to act on medical errors
February 1, 2000 3 minutes read
IOM calls on Congress to act on medical errors
National center, state reporting urged
In drawing national attention to the problem of patient safety and medical errors, the Institute of Medicine in Washington, DC, issued specific recommendations, which are summarized as follows:1
• Congress should create a Center for Patient Safety within the Agency for Health Care Policy and Research in Washington, DC. This center should set the national goals for patient safety, track progress in meeting these goals, and issue an annual report to the president and Congress on patient safety. The center should develop knowledge and understanding of errors in health care by developing a research agenda, funding centers of excellence, evaluating methods for identifying and preventing errors, and funding dissemination and communication activities to improve patient safety.
• A nationwide mandatory reporting system should be established that provides for the collection of standardized information by state governments about adverse events that result in death or serious harm. Reporting should initially be required of hospitals and eventually be required of other institutional and ambulatory care delivery settings. Congress should designate the Forum for Health Care Quality Mea sure ment and Reporting as the entity responsible for promulgating and maintaining a core set of reporting standards to be used by states, including a nomenclature and taxonomy for reporting. Congress should also provide funds and technical expertise for state governments to establish or adapt their current error reporting systems to collect the standardized information, analyze it and conduct follow-up action as needed with health care organizations.
• The development of voluntary reporting efforts should be encouraged. The Center for Patient Safety should describe and disseminate information on external voluntary reporting programs to encourage greater participation in them and track the development of new reporting systems as they form. The center should convene sponsors and users of external reporting systems to evaluate what works and what does not work well in the programs, and ways to make them more effective. The center should fund and evaluate pilot projects for reporting systems, both within individual health care organizations and collaborative efforts among facilities.
• Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that are collected and analyzed by health care organizations for internal use or shared with others solely for purposes of improving safety and quality.
• Performance standards and expectations for health care organizations should focus greater attention on patient safety. Regulators and accreditors should require health care organizations to implement meaningful patient safety programs with defined executive responsibility. Public and private purchasers should provide incentives to health care organizations to demonstrate continuous improvement in patient safety. Health professional licensing bodies should implement periodic re-examinations and re-licensing of doctors, nurses, and other key providers, based on both competence and knowledge of safety practices. Professional societies should make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement.
• The Food and Drug Administration should increase attention to the safe use of drugs by developing and enforcing standards for the design of drug packaging and labeling that will maximize safety in use. The FDA should require pharmaceutical companies to test proposed drug names to identify and remedy potential sound-alike and look-alike confusion with existing drugs.
• Health care organizations should make continually improving patient safety a declared and serious aim by establishing patient safety programs with defined executive responsibility. Patient safety programs should implement non-punitive systems for reporting and analyzing errors within their organizations.
Reference
1. Institute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content