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Push to improve patient safety slow-going

A 1999 report awakened the public to medical errors and sparked efforts to reduce mistakes, but some say much more needs to be done.

After shocking the public with news that medical errors kill up to 98,000 Americans each year in hospitals, a 1999 Institute of Medicine report made numerous recommendations to remedy the problem.

Among them: Create a national center to develop safety goals and fund research on errors and prevention; establish a nationwide mandatory reporting system to track errors and set up a level of voluntary reporting; develop standards to focus attention on patient safety; and launch safety programs and implement medication safety practices through health plans.

Progress has been made on some of these and other IOM suggestions, an encouraging beginning, say many health leaders. But some quality experts say it isn't enough, and they temper their optimism by saying there is still much to be done.

"Have they all been implemented? Hell, no. Some of those things are years in the establishing," said Richard Roberts, MD, president of the American Academy of Family Physicians. "It's kind of like a tugboat nudging an ocean liner; it's slow moving. You do a little nudge here knowing it will change the course miles downstream."

Key reasons why more hasn't been accomplished: The change from the Clinton to Bush administration slowed momentum; public interest has dipped since the initial outrage generated after the report's release in November 1999; and a lack of coordinated efforts has hindered progress. Meanwhile, a Harris Interactive survey released in March found that only 7% of responding physicians had adopted automated systems for prescribing drugs as recommended by the IOM, which advises Congress and the federal government on health policy matters.

"There are fewer tangible results [in hospitals] that one could point to today, but I'm confident that's going to change," said Kenneth W. Kizer, MD, MPH, president and CEO of the nonprofit National Quality Forum in Washington, D.C. "A year and a half isn't all that long."

About 50% to 60% of the IOM recommendations are under way at various levels, said Nancy Foster, coordinator of the Quality Interagency Coordination Task Force, a group created by President Clinton in 1998 to respond to the IOM report, "To Err Is Human: Building a Safer Health System."

The task force detailed more than 100 actions it would undertake alone or with the private sector and state governments. Those initiatives include creating a national focus on reducing errors and ensuring accountability for safe health care delivery.

Wait and see

Despite the push, some physicians and hospitals are waiting to see what programs and policies work best before they get involved, Foster said.

"No, it's not enough," she said of the initiatives. "We know that patients still are dying as a result of medical errors. Everyone would like to reduce that number drastically."

Still, Foster and other industry leaders try to focus more on what has been accomplished since the report -- rather than what hasn't. "What we've seen is not really a rejection or skepticism, but let's get on with it. The question is not whether to do things but how," said Lucian Leape, MD, adjunct professor of the Harvard School of Public Health and an IOM report committee member.

Kenneth Shine, MD, president of the IOM, said the report has placed a greater emphasis on patient safety and the patient as the center of treatment. "The response to the report has been very good," he recently told a gathering of health leaders.

Consider: Congress allocated $50 million this year to establish the national patient safety center. To create the center, the federal Agency for Healthcare Research and Quality renamed one of its programs the Center for Quality Improvement and Patient Safety. The center will educate patients about safety issues and conduct research on how to reduce medical errors and convert findings into improved practices.

Through 2003, AHRQ expects to award up to $25 million each year to establish centers for safety research and practice, and to support other research and education. The agency is looking at defining best practice guidelines to reduce errors.

"We've made a very, very bold start. This is a big problem and we are only getting started," said Gregg Meyer, MD, director of AHRQ's quality and safety center.

No footing on Capitol Hill

Efforts to establish a nationwide error reporting system failed last year. Sen. Jim Jeffords (R, Vt.) drafted a voluntary reporting bill while Sen. Edward Kennedy (D, Mass.) proposed another reporting bill. Neither proposal reached a vote.

This year Jeffords and Kennedy may sponsor joint legislation, said Joe Karpinski, spokesman for the Senate Committee on Health, Education, Labor and Pensions, which Jeffords chairs.

"This issue still does not have a high degree of public, political visibility. It's not the kind of thing congressmen are hearing about from their constituents," Karpinski said. "When you have an issue that doesn't have a big political push from the grassroots, it really takes a consensus to get legislation moving."

President Bush has another idea.

Last month, his administration said it wants to create an Internet-based clearinghouse for medical errors. A patient safety task force was formed to develop the database, which would help the government track mistakes but would not be available to the public. The American Medical Association said any patient safety reporting system must guarantee patient and physician confidentiality.

"To Err is Human" called on states to create reporting systems, starting with hospitals. Last year, 15 states introduced 45 bills related to medical errors. Eight bills became law, including one establishing a patient safety center in New York.

Fifteen states have mandatory reporting from hospitals for adverse events, said the National Conference of State Legislatures. Five other states and the District of Columbia have voluntary reporting. This year, 22 states have introduced legislation related to errors.

Despite the state activity, federal programs are leading the way, said Donald M. Berwick, MD, an IOM report committee member and president and CEO of the Institute for Healthcare Improvement. "The feds are off and running," he said.

The Dept. of Veterans Affairs in May 2000 launched the Patient Safety Reporting System, patterned after the aviation reporting system. It required staff training in patient safety at its 172 medical centers. The VA was a safety leader before the IOM report, consolidating its safety programs in 1997 and creating its National Center for Patient Safety in 1998.

"Everything there [in the report], we had done or were in the process of doing," said James Bagian, MD, director of the VA's patient safety center.

Among other federal efforts: The Dept. of Defense directed its facilities to report mistakes in a confidential database at the Armed Forces Institute of Pathology. The Food and Drug Administration has proposed a new format for prescription drug labeling designed to reduce medication mistakes through clearer and more readable package inserts.

Meanwhile, the National Quality Forum is identifying a list of preventable adverse events to make up core measures for a national error reporting system; developing evidence-based best practices; and establishing quality performance measures for acute care hospitals.

Private sector steps up

Some health plans are heeding the report's call for action. In a pilot program sponsored by Tufts Health Plan and AdvancePCS, about 200 Massachusetts physicians in April began using wireless handheld devices for patient information and electronic prescribing. Minnesota-based Allina Health System has set up medication safety educational programs and automated drug records in hospitals.

"Health plans can help physicians do their jobs better," said Charles M. Cutler, MD, chief medical officer of the American Assn. of Health Plans.

The Leapfrog Group, a consortium of about 80 Fortune 500 companies and other large health care purchasers, plans to use incentives to fuel safety improvements. Employers such as General Motors and IBM have agreed to base purchase of health care on principles encouraging stringent safety measures, including computerized physician order entry and evidence-based hospital referral.

"The group said, 'As purchasers we really want to create some breakthroughs in patient safety,' " said Suzanne Delbanco, PhD, Leapfrog's executive director. "Some employers may use financial rewards for hospitals" that move to implement safety improvements.

Quality experts say the report has prompted many private and public initiatives that will lead to a reduction in medical errors and improving patient safety.

"It's early," Dr. Berwick said. "The story isn't over yet."