Healthcare Executives Need to Do More and Show More for a Safer Health System

Janice Simmons, for HealthLeaders Media , May 21, 2009

Since 1999, progress has been made mostly on voluntary, confidential systems that do not create any external pressures for change. Twenty four states do not have any medical error reporting requirements in place; those states that do require error reporting do not disclose facility-specific information to the public about mistakes. The report suggested a facility-specific reporting of medical harm that is "mandatory, validated and public."

Measuring the problem. The IOM, noting in 1999 that there was no unifying effort to improve healthcare, called for the creation of a Center for Patient Safety within the federal Agency for Healthcare Research and Quality (AHRQ) to coordinate and monitor improvements. However, 10 years later, no national entity exists to comprehensively track patient safety—hindering the ability to tell if improvements have been made.

While AHRQ is attempting to do this, its efforts have been hampered by the lack of reliable medical error reporting. In its May 2009 report, the AHRQ noted that patient safety actually declined by almost 1% a year in the six years after the IOM report was issued in 1999. Ironically, AHRQ still points to the IOM's 1999 report as the best estimate of the magnitude of medical errors, according to the Consumers Union report.

Raising standards for competency in patient safety. The IOM recommended a bigger focus on patient safety by regulators, accreditors, and purchasers. It also called for periodic examinations of doctors and nurses to assess their competence and knowledge of safety practices.

During the past decade, many ideas in patient safety standards have come from the private sector. While these efforts are noteworthy, the results have been fragmented—making it difficult to promote and measure national improvement.

The report noted that the Joint Commission has attempted to use the accreditation process to ensure competency and adoption of its National Patient Safety Goals at hospitals. However, the Commission does not publicly disclose individual hospitals' progress in adopting these goals; its efforts to monitor patient safety sometimes have been criticized.

In the last 10 years, most of the patient safety work done by providers has been on the "confidential side for learning." said McGiffert. "Maybe they've learned something but we sure don't know what the results are."

As the debate over healthcare heats up in Washington, Congress should make sure that improving—and monitoring—patient safety is a central part of any reform legislation it adopts, she adds. Keeping in mind these important issues, hospitals and healthcare organizations—even those that have made big strides is addressing patient safety issues—should see what the Consumers Union report says about transparency and raising standards.

"That is what the public wants to see. You can tell us all you want—that you're doing better," McGiffert said. "But show us the evidence. That's what this report is about."

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Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at

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