Patient safety legislation: A crucial victory

It's long been said that our health care system needs to undergo a transformation in terms of patient safety. The shift must be from a culture of blame into one of openness and prevention, one in which future medical errors are avoided by learning from past mistakes, and one in which the most important questions have to do with why an adverse event occurred.

Yet that goal has been elusive, despite years of hard and productive work on patient safety. A crucial missing ingredient was federal legislation that put the force -- and protection -- of national law behind these bold ideas.

But that ingredient is missing no more.

With last month's overwhelming bipartisan congressional approval of the Patient Safety and Quality Improvement Act of 2005, followed two days later by the president's signature, this bill became law. Now patients and physicians alike can be confident that this crucial step has finally been achieved.

Improving patient safety and quality has been a top priority for the American Medical Association. Enactment of this bill represents the culmination of years of hard work by the House of Medicine and its patient safety partners.

What makes the victory so sweet is that the measure strikes a crucial balance between maintaining confidentiality for reporting error information and ensuring accountability and patients' legal rights. The AMA was part of the core group of health care organizations that developed the principles on which these provisions are based, including the ability to share information for evidence-based research without waiving confidentiality.

Specifically, the law creates a confidential reporting structure in which physicians, hospitals and other health care professionals and entities can voluntarily report information on errors to patient safety organizations without fear of litigation. In turn, these PSOs will analyze the data to develop patient safety improvement strategies. In addition, the measure stipulates that patient safety data will be legally protected and provides appropriate penalties for unlawful disclosures.

But this law will not function in a vacuum, and continued progress is needed. That's why the AMA's interest has been on many levels. In addition to congressional advocacy efforts, the AMA has been involved with education and awareness activities all across the health care sector.

For instance, it is involved with other leading private and public organizations in the Institute for Healthcare Improvement's "100k Lives Campaign," an initiative designed to focus health facility attention on implementing some or all of six best practices proven to reduce patient harm and death. There is also the AMA's Quality of Care Campaign, which seeks to improve the nation's health by focusing on safety, advocacy, measurement and education.

Additionally, the Association continues to support the work of the AMA-founded National Patient Safety Foundation and to be dedicated to promoting health literacy and ending racial and ethnic disparities in health care.

Addressing medical errors is not an easy task. Meeting the challenge will continue to require wide participation. For now, though, the AMA has made clear its position, and Congress and the president have agreed: Safety starts with understanding the root cause of medical errors. This patient safety measure puts in place a foundation upon which a system that fosters such understanding will emerge. The result will be safeguards that prevent errors from recurring and better patient care.