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March 25, 2002 Contact: HHS Press Office
(202) 690-6343

IMPROVING PATIENT SAFETY AND PREVENTING MEDICAL ERRORS


Overview: The Department of Health and Human Services (HHS) plays a critical role in promoting safer health care for all Americans and helping prevent medical errors. Each year, tens of thousands of Americans suffer injuries and death due to preventable medical errors in hospitals, doctors' offices, nursing homes, pharmacies and other places where people receive care. These errors most often result from systemic problems rather than poor performance by individuals.

Since 1998, HHS agencies have served with other federal agencies on the Quality Interagency Coordination (QuIC) Task Force to promote a coordinated effort toward improving the quality of care for patients in America. In 2000, the QuIC task force issued an action plan (available at www.quic.gov) to reduce patient injuries due to medical error, including a series of steps now underway at HHS agencies. In April 2001, HHS Secretary Tommy G. Thompson established a new Patient Safety Task Force to coordinate HHS efforts and work with states and the private sector on one of the most important issues identified in the QuIC report -- the need to improve the collection of patient safety data.

HHS' fiscal year 2003 budget proposal includes $84 million for efforts to improve patient safety and reduce adverse events -- a $10 million increase above the current year's budget. Overall, HHS agencies support a wide range of initiatives designed to reduce preventable medical errors and to improve the quality of care provided to Americans of all ages. These efforts include: collecting and analyzing data to measure quality and target improvement efforts; identifying and promoting best practices to avoid systemic medical errors; and educating consumers and providers about ways to prevent errors.

Background

Preventable medical errors can occur in any health care setting from a wide range of causes. Examples of errors include a patient receiving the wrong medication or a medication to which they have a known allergy or a patient not receiving appropriate care after an abnormal test result. Most often, such errors occur as a result of systemic problems rather than poor performance by individual doctors, nurses or other providers. For instance, drugs with similar names or appearances may be easily confused with one another, or abnormal test results may not be quickly shared with those involved in a patient's care.

In the early 1990s, the Agency for Healthcare Research and Quality (AHRQ) funded a series of research studies examining the frequency and causes of medical errors. Based on these studies, the Institute of Medicine (IOM), an independent body that is part of the National Academy of Sciences, estimated that as many as 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors. The IOM further estimated that adverse events cost the nation $37.6 billion each year -- including about $17 billion associated with preventable errors.

In 1998, HHS and other federal agencies formed the QuIC Task Force to coordinate efforts toward improving the quality of care for patients in America. The task force provides a mechanism for agencies to work together to better measure quality of care and to take steps to improve it. In addition to HHS, the QuIC task force includes the departments of Labor, Defense, Veterans Affairs and Commerce; the Office of Personnel Management; the Office of Management and Budget; the U.S. Coast Guard; the Federal Bureau of Prisons; the National Highway Administration; and the Federal Trade Commission.

In November 1999, the IOM issued a comprehensive report, "To Err Is Human: Building A Safer Health System," that focused public attention on the need for research, data and reforms to reduce medical errors and improve patient safety. The report included wide-ranging recommendations for both the public and private sectors for improving patient safety in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.

Following the report, the QuIC task force issued an action plan in February 2000 that highlighted a series of steps for HHS and other federal agencies to take to reduce medical errors. In addition, HHS continues to expand its efforts to improve patient safety by gathering and analyzing data, conducting relevant research, and educating consumers, businesses and health care providers about preventing medical errors.

Data Collection and the HHS Patient Safety Task Force

Federal and state agencies, accrediting bodies and other organizations collect data that can provide insights into the causes of medical errors and strategies to increase patient safety, but these separate sources of information are difficult to compare and analyze. In April 2001, Secretary Thompson created the HHS Patient Safety Task Force to coordinate the efforts of these various data-collection sources to promote more consistent, effective use of the information.

The secretary directed the task force to identify the data that health care providers, states, and others need to improve patient safety and will work to develop a less-burdensome reporting system that avoids duplication, increases efficiency and allows providers to learn from others' experiences. This system will provide reliable, valid information to identify safety risks and to develop solutions. All the data collected will be de-identified, with references to individual patients, doctors and facilities eliminated in order to encourage reporting and to protect individual privacy.

This system will be built upon data from existing reporting systems, such as adverse events reported to the Food and Drug Administration (FDA) and voluntary reports of hospital-related infections to the Centers for Disease Control and Prevention (CDC). Information about existing reporting requirements is available at www.ahrq.gov/qual/taskforce/hhsrepor.htm.

The new system will complement efforts at the Centers for Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing Administration, to develop and implement a confidential Medicare patient safety monitoring system that will describe patterns and trends of adverse events in hospitals. This monitoring system will provide information on the causes of errors broadly, but not at the level of an individual hospital.

Promoting best practices to prevent errors

Since March 1998, the QuIC task force has worked to coordinate the quality of care activities in federal agencies involved in health care. In September 2000, the task force sponsored a national summit on medical errors and patient safety research that included health care providers, administrators, purchasers, policymakers, oversight groups and consumers to address future research needs.

AHRQ included the input from the summit in developing a research agenda to guide funding decisions of public- and private-sector organizations that support patient safety research. The agenda includes efforts to design and test "best practices" for reducing errors, develop the science base to inform these efforts, improve provider education to reduce errors, capitalize on advances in information technology, and build the capacity to further reduce errors.

Based on the research agenda, AHRQ awarded $50 million in fiscal year 2001 to support 94 new research grants, contracts, and other projects to reduce errors and improve patient safety. This initiative represents the federal government's single largest investment to address patient safety issues. The 94 projects are being carried out at state agencies, major universities, hospitals, outpatient clinics, physicians' offices, and other settings across the country. More information on these projects is available at www.ahrq.gov/qual/newgrants/index.html.

HHS agencies are also involved in a number of other projects to promote patient safety:

Improving drug labeling. The FDA in December 2000 proposed a new, user-friendly format for prescription drug labeling designed to reduce the chances of making medication errors, such as giving the wrong dose or causing adverse interactions between drugs. The system would include a bulleted "highlights" section with information that clinicians are likely to need and review frequently.

Reducing "high-hazard" risks. The QuIC task force is working with the Institute for Healthcare Improvement to test strategies for reducing the number of errors committed, particularly in emergency rooms, operating rooms, intensive care units and on-site rescue operations. This is the first such initiative targeted at error reduction in these "high-hazard" environments.

Developing quality measures. In 2001, CMS launched a quality initiative to help people who rely on Medicare and Medicaid programs and their family members find the best nursing homes for their needs. Initially, CMS will identify, collect and publish nursing home quality information in Colorado, Florida, Maryland, Ohio, Rhode Island and Washington, and then will work to expand the demonstration nationally. Over the next several years, CMS will work to develop and publish similar, meaningful consumer information for home health agencies, and eventually hospitals and other types of providers. This information will give beneficiaries, their families and their physicians the information they need to make informed choices of their providers. CMS and AHRQ continue to work with the National Quality Forum, a private group of major employers and other purchasers of health care, to identify and evaluate quality measures.

Medicare Quality Improvement Organizations (QUIs). Through State Quality Improvement Organizations (QIOs), formerly known as Medicare's Peer Review Organizations (PROs), CMS is conducting 14 local pilot projects aimed at improving patient safety. Successful efforts will be expanded in order to improve quality of care across larger groups of patients. CMS already has established a number of national priorities for PROs to improve patient safety, including reducing the use of contra-indicated treatments and eliminating unnecessary treatment delays.

Educating patients and health care providers

Well-informed patients and health care providers can play a critical role in preventing medical errors. HHS devotes a wide array of resources to education materials targeted at consumers and providers alike. These efforts include:

Consumer guides. HHS has numerous pamphlets and guides on preventing medical errors for consumers in both English and Spanish, including "20 Tips to Help Prevent Medical Errors," a practical guide with research-based recommendations involving potential safety risks related to medications, hospital stays and surgery, and "Five Steps to Safer Health Care," highlighting ways that patients and their families can take more control over the quality of their health care. These and other consumer publications are available atwww.ahrq.gov/qual/errorsix.htm.

Research-based information for providers. AHRQ shares evidence-based information from research about best practices to avoid medical errors in easy-to-use formats for doctors, other clinicians and health care providers. "Making Health Care Safer: A Critical Analysis of Patient Safety Practices," an AHRQ evidence report, is a review of 79 patient safety practices with a list of 73 that are likely to improve patient safety and a description of 11 that the researchers considered highly proven to work but are not performed routinely in the nation's hospitals and nursing homes. HHS agencies also hold interactive workshops and satellite broadcasts to share important research findings and other information about patient safety. Other efforts include summaries of best practices, including a general guide to promote patient safety, as well as other documents geared to specific topics, such as reducing adverse drug events in hospitals. AHRQ's evidence report on patient safety practices and many other reports are available at www.ahrq.gov/qual/errorsix.htm.

Outreach to states. AHRQ has partially funded a series of reports to educate state policymakers, including legislators and state health officials, to highlight steps that states can take in order to improve patient safety and reduce medical errors. The reports, prepared by the National Academy of State Health Policy, deal with topics such as state-mandated reporting of medical errors and working with the private sector to improve patient safety. The reports are available at www.nashp.org.

Medication errors information. The FDA provides updated information about medication errors, including specific drugs that have been confused with one another. The information reflects analysis of voluntary reports from consumers, doctors and other clinicians, as well as mandatory reports from manufacturers. Details are at www.fda.gov/cder/drug/MedErrors/. FDA also runs the "Take Time to Care" awareness campaign to educate women and families about taking medications correctly. The effort includes consumer literature, as well as local, interactive educational sessions led by pharmacists and other health professionals. More information is available at www.fda.gov/womens/tttc.html.

National health information infrastructure. In 2001, the National Committee on Vital and Health Statistics, which advises HHS on health information policy, issued a report outlining a strategy for developing a comprehensive national health information infrastructure that would help reduce medical errors. The committee's report is available at www.ncvhs.hhs.gov/nhiilayo.pdf.

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Last revised: March 25, 2002