Remarks on Efforts To Improve Patient Safety

Weekly Compilation of Presidential Documents, Feb 28, 2000

February 22, 2000

Thank you very much. Let me begin by thanking Barbara Blakeney for her words and her work on the frontlines of health care, and for the true visionary leadership that the nurses of our country have given efforts for health care reform certainly for all the days that I have been privileged to be here as President, and long before.

I want to thank Secretary Shalala and Secretary Herman for the work that they have done on the whole issue of quality health care, on medical errors, and their pioneering work for the Patients' Bill of Rights.

I thank Senator Jeffords, Senator Specter, and Senator Harkin for being here. They had an important hearing today, and I can tell you that--I was talking to them for a few moments outside--they are passionately interested in and very well informed about this issue. And as we all know, when we have a bipartisan commitment in the Congress to solving a problem in America, it normally gets solved. And I thank you all very much for your dedication.

I want to thank all the people who are here from the National Government. John of AHRQ--I like that. That's pretty good. [Laughter] Tom Garthwaite, Sue Bailey, Paul London, all the people here from all the other agencies who have worked so hard on this. Thank you very, very much. Thank you, Ken Kizer. I thank the leaders representing consumers, health care plans and providers, business, labor, and quality experts who are here. And of course, I want to thank the National Academy of Sciences' Institutes of Medicine for its landmark report.

As Secretary Shalala said, the IOM study focused new light on what has been a high priority of ours, which is ensuring that all Americans get the highest quality health care in the world. Secretary Herman pointed out that this is about more than saving lives-the dollar cost of-it is about more than money-and it's even about more than saving lives, because it's about the toll in lost trust in the health care system. We heard a lot about it when the IOM study came out.

But we know that if we do the right things, we can dramatically reduce the times when the wrong drug is dispensed, a blood transfusion is mismatched, or a surgery goes awry. As I have said many times, I will say again, I'm not here to find fault. I'm here to find answers.

We do have the best health care system in the world, the finest health professionals in the world. New drugs, new procedures, new technologies have allowed us to live longer and better lives. Later this year, when researchers finish the mapping of the human genome, it will lead to even greater advances in our ability to detect, treat, and prevent so many, many diseases.

But the growing advances have been accompanied by growing complexity in our health care delivery system. I might say it's complicated by the choices we have made about how we finance it and operate it. So the time has plainly come, as a result of the IOM study, to just take a step back and ask ourselves: How can we redesign the system to reduce error? Have we given all of our caregivers adequate training? Do they adequately coordinate with and communicate with one another? Do all settings have the right kinds of teams and systems in place to minimize mistakes?

These are the kinds of questions that were asked and answered in our landmark efforts as Americans to improve aviation safety and workplace safety. And if these questions are properly asked and answered in the context of the health care system, they will dramatically reduce errors there as well.

Last December I directed our own Health Care Quality Task Force to analyze the IOM study, to report back with recommendations about how we can follow the suggestions they made to protect patients and promote safety. This morning I received the task force report, and I am proud to accept all its recommendations.

Our goal is to reduce preventable medical errors by 50 percent within 5 years. Today I announce our national action plan to reach that goal.

First, we agree with the need to establish a focal point within the Federal Government to target this challenge. So today I propose the creation of a new center for quality improvement in patient safety. My budget includes $20 million to support the center, which will invest in research, develop national goals, issue an annual report on the state of patient safety, and translate findings into better practices and policies.

Second, we will ensure that each and every one of the 6,000 hospitals participating in Medicare has patient safety programs in place to prevent medical errors, including medication mistakes. These new systems save lives and over time, of course, also save money. I commend hospitals for the steps they have already taken, and we'll work with them and other health care experts to develop this regulation in the coming months.

Third, as we seek to make sure that the right systems are in place, we need to make sure they are working. Today I am releasing our plan for a nationwide, State-based system of reporting medical errors to be phased in over time. This will include mandatory reporting of preventable medical errors that cause death or serious injury, and voluntary reporting of other medical mistakes and so-called near misses or close calls.