Testimony Before the Subcommittee on Health of the House Committee on Ways and Means Hearing on Legislation to Reduce Medical Errors

September 10, 2002

The Need for Greater Attention to Patient Safety

"The Institute of Medicine's (IOM) landmark 1999 report, To Err is Human, alerted the nation to the patient safety challenge in ways that prior studies had not. The IOM estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors, making them the eighth leading cause of death in the United States. More people die from medical errors than from automobile accidents, breast cancer, or AIDS. While there has been subsequent debate about the actual number of deaths, it is clear that the rate of medical errors is unacceptably high.

"I would like to highlight four of the IOM conclusions that are particularly relevant to today's hearing. First, the elimination of medical errors will not be accomplished by attempting to identify and discipline the 'bad apples'. The IOM report concludes that errors are not solely the fault of individual doctors, nurses, and other clinicians; they are often 'a failure in the process of delivering care in a complex delivery system.' System failures result from a complex interaction of people, technology, work processes, and working conditions, but few health care providers have expertise in the identification and analysis of contributors to system failures.

"Second, the IOM report cautions that if a patient experiences an adverse event during the process of care, this does not necessarily mean that a medical error has occurred. Most medical care entails some level of risk, and there can be complications or side effects, even unforeseen ones, from the underlying condition or from the treatment itself. We should not equate problem outcomes with bad practice, but, rather, we should strive to differentiate one from the other.

"Third, the IOM concluded that much can be learned from the analysis of errors--from errors that result in serious patient injury or death as well as from errors that result in little or no patient injury, but which, when aggregated, can help identify patterns of system failures. To foster such analyses, the IOM urged health care organizations to implement non-punitive systems for reporting and analyzing errors within their organizations and encouraged the development of voluntary reporting systems.

"Fourth, the IOM concluded that health care providers need to be assured that if they report errors that are necessary to detect system problems, these reports will be used for that purpose in a culture of safety rather than unproductively as grist for the litigation mill..."

Role of QIOs in Patient Safety

"CMS and the QIOs are working to improve clinical health outcomes of Medicare Beneficiaries and to prevent clinical disorders in a variety of health care settings.

"For instance, QIOs work with nursing homes in their states using the publicly reported Minimum Data Sets quality of care measures developed by CMS. QIOs also provide information to Medicare beneficiaries and their families, which can be used for selecting nursing homes, improving nursing home care, and obtaining a better understanding about nursing home care.

"Likewise, QIOs are working with home health agencies in their states, using the publicly reported OASIS quality of care measures developed by CMS. As with nursing homes, the QIOs provide information to Medicare beneficiaries and their families.

"QIOs also are continuing work with hospitals to reduce medication and other system failures related to acute myocardial infarction, heart failure, and pneumonia, and are adding a new clinical area focus, the prevention of surgical infection. The QIOs also focus some of their efforts on Critical Access Hospitals.

"Furthermore, in physician offices, QIOs are continuing work in the areas of care for chronic diseases like diabetes and preventative services like mammography and adult immunizations for flu and pneumonia.

"In addition to these various clinical settings, QIOs are focusing on different populations. They will continue work to eliminate health disparities between certain medically underserved populations and the general population. We also have added rural beneficiaries to the list of the groups eligible for these projects.

"And QIOs will continue work to ensure that Medicare+Choice Organizations are part of CMS' overall efforts to improve health outcomes and enrollee satisfaction for beneficiaries enrolled in a Medicare+Choice Organization.

"In addition to clinical quality improvement, QIOs are helping to improve patient safety and health through helpful information and effective communication. The QIOs play an active role in communicating publicly reported nursing home and home health agency quality of care measures; and provide assistance to providers and beneficiaries in their states in interpreting and using this information.

"Additionally, through coordination with JCAHO, the QIOs are assisting hospitals in their states in developing the infrastructure and tools to permit electronic self-reporting of quality of care measures…"

"QIOs are also dedicated to improving beneficiary safety through Medicare beneficiary protection activities. The QIOs continue to provide review and beneficiary complaint responses as required by law and regulations. Additionally, the QIOs have implemented a new element of the beneficiary complaint response program utilizing the mediation process to supplement the more formal complaint review procedures."