Unhappy anniversary: poor progress on patient safety

Health Management Technology, Dec, 2004

Patient safety initiatives are underway at scores of healthcare facilities, but pressure is building again because of lack of sufficient progress in the five years since the 1999 Institute of Medicine (IOM) report first identified the magnitude of the medical error problem in the U.S.

A news release from Reuters Health in November quotes experts on the failure of Congress to implement error reporting legislation, including Dr. Lucian L. Leape, Harvard University health policy professor and a member of the committee that issued the IOM report, "To Err is Human: Building A Safer Health System." Leape points out that AHRQ, the federal agency responsible for health safety studies, has a budget this year of $60 million, nearly 500 times lower than that of the National Institutes of Health. "Dollars have not materialized to do what needs to be done," Leape said.

Dr. Robert M. Wachter, who co-authored the report, indicated that too little progress has been made in hospitals since 1999, and shared results of a 400-hospital survey in which only 45 percent of the facilities reported having "a better culture of safety" than they did in 1999, and 55 percent report the same or worse safety conditions.

Wachter, a strong supporter of the Patient Safety and Quality Improvement Act (S. 720) which passed the U.S. Senate in July but has not yet passed into law, did have praise for organizations like Joint Committee for Accreditation of Hospital Organizations (JCAHO) for tightening safety practices in the hospitals, but joined in a chorus of experts criticizing the practice of keeping too much of its data secret. Some advocates seek more public reporting of safety data to encourage improvement by doctors and hospitals.

Wachter acknowledged that many states now require health workers to report medical errors or "near misses" in which a patient is put at potential risk. But the research reports have largely not been used. "They have not been translated into action," he said.