Joint Commission president testifies before U.S. Senate on critical strategies for reducing medical errors

The most powerful incentive for reducing medical errors is to align payments for service with the successful provision of safe, high quality care, the president of the nation's leading advocate for health care quality and safety told a United States Senate Committee today.

Testifying before the U.S. Senate Committee on Governmental Affairs, Joint Commission President Dennis S. O'Leary, M.D., outlined six crucial strategies for the creation of a true culture of safety within health care institutions.

"The Joint Commission, like others, is deeply concerned that the number of serious medical errors remains unacceptably high, despite the focus of significant national attention on patient safety in recent years,"' says Dr. O'Leary.

To overcome the barriers preventing health care organizations from truly embracing patient safety, O'Leary emphasized that Congress, health care providers and purchasers need to work together to:

- Create a blame-free, protected environment that encourages the systematic surfacing and reporting of serious adverse events.

- Reinforce the "systems approach" to preventing medical errors, whereby health care organizations assess the weak points in their systems of care and re-design care processes by putting safeguards into place to keep mistakes from reaching the patient.

- Reform the professional educational system to produce health care professionals who are proficient in executing a "systems approach" to patient safety and are trained in team approaches to patient care.

- Invest in the information infrastructure of health care organizations in order to make critical patient information available on a timely basis and thereby support the safe and appropriate delivery of medical care to patients.

- Establish performance incentives for achieving safety objectives through federal adoption of the Joint Commission's National Patient Safety Goals, and align reimbursement for health care services with the provision of safe, high quality care.

Enact patient safety legislation that that would encourage the voluntary reporting of health care errors and their causes by affording confidentiality protections for such reports.

"Health care professionals, who work under continuous high stress, will make errors," says Dr. O'Leary. "The goal is to prevent those errors from reaching or affecting the patient."

The Joint Commission maintains one of the nation's most comprehensive databases of serious adverse events and their underlying causes. Information from this database is regularly shared with accredited organizations to help them take appropriate preventive steps. It is also used to establish the National Patient Safety Goals. It is believed that the sharing of this information has already saved countless lives,

The Joint Commission's National Patient Safety Goals, implemented in January 2003, set forth clear, evidence-- based recommendations to focus health care organizations on significant documented safety problems. Accredited health care organizations that provide care relevant to the Goals are evaluated for compliance with these Goals.

"There are considerable barriers to be overcome if we are to be successful in persuading health care organizations and practitioners to fully embrace state-of-the-art patient safety and health care quality practices," says O'Leary. "The knowledge of what to do differently and how to do it exists and progress is being made. However, more needs to be done by all of us, including the Congress, if we are to succeed."

To view the testimony online go to: http://www.jcaho.org