Attacking Roots of Medical Errors

Health care quality has been a front-burner concern in Washington ever since an Institute of Medicine report last fall concluded that preventable medical errors annually kill up to 100,000 patients and run up $29 billion in costs, mostly in lost labor and expensive hospital stays.

Both Democrats and Republicans are for the first time beginning to put solutions on the table. Last week Congress held hearings at which doctors, patients and health policy experts said Congress could prevent tens of thousands of serious medical injuries each year simply by requiring hospitals, pharmacies and other health providers to report errors to independent reviewers, who then would figure out why the errors came about and how to prevent them.

Sen. Arlen Specter (R-Pa.) plans to introduce legislation in the next two weeks that would fund a federal study into how to compel such reporting. Specter rightly suggests that the reporting of most medical mistakes might have to be kept confidential because of a factor emphasized by one witness. Lucian Leape, a Harvard University public health professor, told the legislators that the “only real barrier” to effective medical error reporting is fear. “It’s the fear that every doctor and nurse has, that they’ll make a mistake. And it’s the fear of the consequences of that mistake, [that] they’ll hurt a patient, that it will become public, that they’ll be ridiculed or disciplined or sued.”

This fear has grown in recent months as legislators in Washington, and in Sacramento and other state capitals, pressed bills that would greatly expand legal liability for errors.

Health care providers should, of course, be held accountable for serious medical errors. To that end, the Clinton administration should require hospitals that receive government funding to at least report what health care experts call “sentinel events”--truly serious injuries, like removing the wrong kidney. More often, however, errors occur not because of individual recklessness but because of the way the health care delivery system is organized; for instance, when a pharmacist misreads a physician’s handwriting or when a toxic dose is given because of hospitals’ tendency to stock certain drugs in concentrated forms that may be harmful unless diluted. All detectable errors should of course be tracked, but not all errors need have names attached to them.

This spring, a group of large private employers including General Motors, Dell Computer and GTE will launch what it calls the Leapfrog Initiative, a program aimed at contracting only with health providers that agree to take specific steps to reduce medical errors. One simple step is requiring physicians in hospitals to enter prescriptions on a computer. The Clinton administration should join the initiative and direct government business to “Leapfrog-certified” hospitals.

In the last decade, U.S. industries like airlines, nuclear power and chemical manufacturing have implemented sophisticated error-prevention systems, realizing that mistakes more often have to do with the flaws of systems than with the people using them. Now, legislators have to help health providers and the private sector extend that same wisdom to medicine.