The extent of medical error was brought to the attention of the general public in

1999 with the InstituteTo ofErris HumanMedicine’s.Thestudy (IOM’s found that over half of the adverse events at two major hospitals related to

medical errors. It went on in chilling detail, describing people who had died from mistakes, had the wrong limbs amputated, or suffered serious health crises. The

Joint Commission defines medical error as omission or commission) or one that does not achieve its

Some medical errors are caused by true accidents, but most are caused by errors, such as failing to follow a standard of care. Unfortunately, many errors are systematic and related to ineffective processes, such as a failure in communication or insufficient staffing, making it difficult to pinpoint responsibility. Further compounding the problem is that many malpractice insurance policies explicitly state that the insured should make NO admission of liability, despite this being directly counter to medical ethics. (In response to this, some states have

passed legislation that explicitlynotanadmissionstates th of negligence.) Medical errors can be frightening for patients, but those who

commit errors may be very shaken by the experience, feeling guilty and fearful of losing their jobs, losing respect of others, and being sued.

Goals and regulations

There is a growing consensus that medical errors must and CAN be controlled and increasing regulations requiring that they be reported. The Joint Commission has issued the 2008 National Patient Safety Goals, providing strict standards to improve patient safety and reduce medical errors.

Link:

Joint Commission 2008 National Patient Safety Goals

It’s important to realize that these safety accreditation assessment in an effort to reduce medical errors, but they do not

cover all potential errors.  Procedures are in place for reporting of sentinel events

(unexpected events not related to a patient’ injury), and compliance with safety goals is assessed during accreditation.

The Federal Center for Medicaid and Medicare Services has issued a new rule that will take effect October 2008. Under this rule, hospitals will not be reimbursed for treatment related to preventable conditions, such as those related to medical error or improper care. Additionally, the costs cannot be conferred upon the patient, so institutions must absorb the costs related to medical errors. This provides a strong motivating force for compliance. Medicare payments have been based on diagnosis-related groups (DRGs), but institutions can apply for a higher reimbursement rate if complications occur. Thus, institutions that increased infection rates or complications received higher reimbursement and those that decreased infection rates also decreased profits—not exactly a motivation to improve care. Eight secondary conditions have been identified as no longer qualifying for additional payments because they are preventable:

This change in reimbursement cancels the monetary advantage of providing poor care to some degree although the changes are not so clear because when costs substantially exceed the DRG, reaching a threshold amount, Medicare will still provide higher reimbursement. However, the real impetus is related to knowing that this is the beginning step in making organizations accountable, not the last step.

While awaiting federal action, some states have enacted their own regulations to improve safety, and some now require reporting of hospital-acquired infections and/or reporting of MRSA infections, and 25 states currently require mandatory reporting of medical errors. Adverse event reporting rules and statutes for all states that include some type of mandatory reporting are available at the National Academy for State Health Policy. There is an alphabetical listing of states with links to rules and statutes:

National Academy for State Health Policy, state links

Florida is a good example of government and public concerns spurring legislation, sometimes at odds with each other. In 2004, the Florida Legislature passed cutting-edge legislation requiring that information about patient outcomes, such as mortality rates and infection rates, be made public and that patients be notified when they were involved in an adverse event. It also mandated patient safety education for healthcare providers. Florida set up the Florida Patient Safety Corporation, which established a voluntary reporting

system for-misses,”“near assuring anonymity, which m essential to honest reporting.

However, in 2004, voters approved two amendments backed by the Florida Trial Attorneys:

• Patient’s Right   to   Know  about   Adverse   Med

7), which allows patients access to all records about their care (including previously protected peer review findings).

• Three Strikes and You Are Out Act (Amendment 8), which provides for revocation of license to practice for physicians with 3 adjudicated

malpractice suits.

While the legislature has made some modifications trying to align the different regulations, the result has been an increase in out-of-court settlements because physicians fear losing a judgment and endangering their licenses, and a marked decrease in reporting of medical errors because anonymity is not protected. Currently, medical errors must be reported (Code 15 report) to the state within 15

days. Monthly and annual reports of adverse events (deaths, injury) are available online. Link:

Florida Risk Management Data

Florida’s                        Amendment   7   is   also   at   odds  with   t

Improvement Act (2005), which established a national database for reporting of voluntary information about medical errors in order to develop more effective safety measures. This act ensures confidentiality. The need for clear national policy is evident.