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U.S. Health Care System Fails to Protect Patients From Deadly Medical Errors
Date:5/20/2009

facility-specific reporting of medical harm that is mandatory, validated, and public.

Measure the Problem: In its 1999 report, the IOM noted that there was no cohesive effort to improve health care and 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. Ten years later, we still have no national entity comprehensively tracking patient safety and are unable to tell if we are any better off than we were a decade ago. AHRQ is attempting to do this, but its efforts are hamstrung by the lack of reliable medical error reporting. In its May 2009 report, the AHRQ noted that patient safety actually declined by almost one percent a year over the six years after the IOM report was issued in 1999 and stated that "[d]ata remain incomplete for a comprehensive national assessment on patient safety." The AHRQ still points to the IOM's 1999 report as the best estimate of the magnitude of medical errors.

Raise Standards for Competency in Patient Safety: The IOM recommended a greater focus on patient safety by regulators, accreditors, and purchasers and called for periodic examinations of doctors and nurses to assess "both competence and knowledge of safety practices." Over the past ten years, many initiatives to improve competency in patient safety standards have come from the private sector. While these efforts are laudable, the results have been fragmented and no process exists to promote and measure national improvement. The Joint Commission has attempted to use the accreditation process to ensure competency and adoption of its National Patient Safety Goals at hospitals. But the Commission does not publicly disclose the progress that individual hospitals have made adopting these goals and its efforts to monitor patient safety often have been criticized. There is scant evidence that physicians, nurses, and other
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SOURCE Consumers Union
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