Safety reporting now in Senate's hands

About a year ago this week, hospitals and health care organizations around the country were observing the second annual Patient Safety Awareness Week -- a time to focus on their commitment to quality and to educate patients on how to become involved in their own health care.

At the very same time, the U.S. House of Representatives took an important step toward bolstering local quality efforts by passing the Patient Safety and Quality Improvement Act. The bill would create a voluntary system for reporting medical errors, and for analyzing and disseminating information on those mistakes so that physicians and others could prevent them in the future. The measure passed unanimously last July in Senate committee but never made it to the full Senate floor for a vote.

Fast forward. It's 2004. The National Patient Safety Foundation is again holding its Patient Safety Awareness Week, March 7-14. There could not be a more fitting time for the Senate to follow the precedent set by the House a year ago and turn its attention to passage of the medical error reporting bill.

In today's medical system, the fear of being sued discourages doctors, nurses and other health professionals from reporting medical mistakes. In the end, everyone loses, because patterns of errors aren't discovered and the faulty systems of care that allowed the mistakes to occur remain in place.

Only by shifting from what organized medicine calls the "culture of blame" to one of error prevention can patient safety be achieved. The legislation, supported by the American Medical Association, would accomplish this switch by making error reporting voluntary and confidential.

Hospitals and doctors would share information about mistakes with government-certified patient safety organizations, which then would study the data and distribute protocols and best practices that could be adopted at the local level to prevent future medical errors.

The information gathered in this reporting process would be considered confidential and could not be used in legal actions against doctors. This would create the safe environment necessary for physicians and others to freely disclose medical errors.

This new system, however, would not absolve doctors and others from accountability to patients when errors are made. The legislation would not limit the availability of information or evidence that can be collected under existing law.

The bill got a boost last month when Senate Majority Leader Bill Frist, MD (R, Tenn.), announced that the patient safety bill is one of the items on his legislative agenda that he would like to get to President Bush's desk as soon as possible. Passage of the measure, which he co-sponsors, would save thousands of lives, he told a gathering of health care reporters.

Physicians have a major role in the effort to improve health care quality. They can take Patient Safety Awareness Week to heart not only by participating in any associated events in their communities, but also by contacting their senators and urging them to pass the medical error reporting bill this year.

A combination of grassroots patient safety activism and congressional action could go a long way toward creating a strong patient safety culture in America's communities.