# Presentation: 578531

## Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their ImpactReport of the Quality Interagency Coordination Task Force 

- February, 2000

## Institute of Medicine ReportTo Err is Human: Building a Safer Health System

**Preventable medical errors**
- 44,000 to 98,000 Americans die each year
- Eighth leading cause of death in the United States
- Annual cost as much as $29 billion annually
- IOM conclusion: the majority of these problems are systemic, not the fault of individual providers

## Institute of Medicine Report

**Four-tiered approach to reducing medical errors**
- Establish national focus on patient safety
- Identify and learn from medical errors through mandatory and voluntary reporting systems
- Raise standards and expectations for improvement through oversight, group purchasers, professional groups
- Implement safe practices at the delivery level

## Administration Actions on Quality

- Early 1997 - President establishes the Advisory Commission on Consumer Protection and Quality in the Health Care Industry
- 1998 - President establishes the Quality Interagency Coordination (QuIC) Task Force
- 1998 - Vice President launches the National Forum for Health Care Quality Measurement and Reporting

## Current Federal EffortsResearch Activities

- Agency for Healthcare Quality and Research (AHRQ)
- Sponsors research into frequency and causes of medical errors
- Tests techniques designed to reduce medical errors
- VA Centers for Research on Patient Safety

## Current Federal EffortsData Collection

- CDC - infections
- FDA - drugs, devices, biologics
- VA reporting system on medical error
- AHRQ - administrative data from hospitals

## Current Federal EffortsImproved Safety Practices

- Veterans Affairs
- Computerized physician ordering system
- Computerized patient record system
- Barcoding technology for medication administration
- Drug interaction software
- Defense
- Computerized physician ordering system
- Drug interaction software

## Current Federal EffortsHealth Care Purchasing

- HCFA
- Medicare “Conditions of Participation” - address quality of care
- Veterans Affairs
- Uses purchasing power to demand safe packaging/labeling of drugs it buys
- Office of Personnel Management
- Announced it will require meaningful patient safety programs in all FEHB plans by 2001

## The President directed the QuIC to respond to the IOM’s report
Evaluate the recommendations in To Err is Human
Identify prevalent threats to patient safety
Identify ways to reduce medical errors throughout the nation’s health care system

- Evaluate the recommendations in *To Err is Human*
- Identify prevalent threats to patient safety
- Identify ways to reduce medical errors throughout the nation’s health care system

**Federal Response**

## Establish Center for Quality Improvement and Patient Safety (CQuIPS) at AHRQ:
Conduct research into medical errors reduction
Convert findings into improved practices
Educate patients about their safety
Conduct National Summits within One Year
AHRQ - Patient safety research and practices
FDA - Drug and device safety
VA - Patient safety practices

- Conduct research into medical errors reduction
- Convert findings into improved practices
- Educate patients about their safety
- Conduct National** **Summits within One Year
- AHRQ - Patient safety research and practices
- FDA - Drug and device safety
- VA - Patient safety practices

**Federal Response - Leadership**

## HCFA - Will publish regulations requiring hospitals participating in Medicare to have ongoing medical error programs in place
OPM - Will require all plans in FEHB to seek accreditation that includes evaluation of patient safety and programs to reduce errors
VA/DoD - Continue to lead providers by example

- OPM - Will require all plans in FEHB to seek accreditation that includes evaluation of patient safety and programs to reduce errors
- VA/DoD - Continue to lead providers by example

**Federal Response - Model Programs**

## Goal: Nationwide system of state-based reporting
Quality Forum will:
Select measures of safety that should be part of any reporting system
Identify proven patient-safety practices
Define, within 12 months, egregious preventable errors that should never occur
QuIC to:
Urge public disclosure of provider use of Forum-identified proven patient-safety practices
Collect, as appropriate select measures that should be part of any reporting system

- Quality Forum will:
- Select measures of safety that should be part of any reporting system
- Identify proven patient-safety practices
- Define, within 12 months, egregious preventable errors that should never occur
- QuIC to:
- Urge public disclosure of provider use of Forum-identified proven patient-safety practices
- Collect, as appropriate select measures that should be part of any reporting system

**Reporting Systems**

## Reporting Systems - State

- State Mandatory Data Collection to Include
- Information on select group of errors leading to serious harm or death
- Information on proven patient safety practices
- Never a shield for illegal/negligent behavior
- Voluntary component
- Errors and “close calls”
- Confidential --- peer review protections
- Data to be shared in national data set for research on patient safety

## HCFA
Pilot mandatory reporting in 100 hospitals that volunteer
Pilot program with a State with mandatory reporting to test data collection on egregious errors 
VA will add new voluntary data collection to augment existing mandatory
DoD will institute system modeled on VA system
OPM will require health plans in FEHB to describe patient safety initiatives in publications

- Pilot mandatory reporting in 100 hospitals that volunteer
- Pilot program with a State with mandatory reporting to test data collection on egregious errors
- VA will add new voluntary data collection to augment existing mandatory
- DoD will institute system modeled on VA system
- OPM will require health plans in FEHB to describe patient safety initiatives in publications

**Reporting Systems - Federal**

## AHRQ
Lead effort to evaluate existing reporting systems
Include errors in National Quality Report
Integrate data from different sources
VA
Establish voluntary system to supplement existing mandatory system

- Lead effort to evaluate existing reporting systems
- Include errors in National Quality Report
- Integrate data from different sources
- VA
- Establish voluntary system to supplement existing mandatory system

**Building on Reporting Systems**

## DoD
Develop reporting system modeled on VA system - 6 months
FDA
Expand mandatory reporting for blood banks to all 3000 registered blood establishments
Implement Phase II of MedSUN

- Develop reporting system modeled on VA system - 6 months
- FDA
- Expand mandatory reporting for blood banks to all 3000 registered blood establishments
- Implement Phase II of MedSUN

**Building on Reporting Systems**

## QuIC
Promote collaborative efforts with public and private sector partners to increase providers’ and purchasers’ awareness of scope of medical errors problem
Collaborative project with Institute for Healthcare Improvement to reduce errors in high hazard settings

- Promote collaborative efforts with public and private sector partners to increase providers’ and purchasers’ awareness of scope of medical errors problem
- Collaborative project with Institute for Healthcare Improvement to reduce errors in high hazard settings

**Additional Actions to ****Improve Safety**

## FDA
Improve standards for drug naming, packaging and labeling
Conduct public education effort
DOL
Encourage health care purchasers to consider patient safety through the Health Benefits Education Campaign

- Improve standards for drug naming, packaging and labeling
- Conduct public education effort
**DOL**
- Encourage health care purchasers to consider patient safety through the Health Benefits Education Campaign

**Additional Actions for Improving Safety**

## AHRQ
$20M in FY01 for research into causes and remedies
Disseminate approaches to improving patient safety
Patient Safety Clearinghouse
Expand research on informatics
Initiate “National Morbidity & Mortality Conference” via Internet technology
FDA 
$33 million for enhanced reporting

- $20M in FY01 for research into causes and remedies
- Disseminate approaches to improving patient safety
- Patient Safety Clearinghouse
- Expand research on informatics
- Initiate “National Morbidity & Mortality Conference” via Internet technology
- FDA
- $33 million for enhanced reporting

**Investment in Improving Safety**

## VA
$47.6M to increase patient safety training for staff
$75.1M for order entry system, barcoding
DoD
$64M in FY01 to introduce electronic medical records
$12M for automated order entry system for pharmaceuticals

- $47.6M to increase patient safety training for staff
- $75.1M for order entry system, barcoding
**DoD**
- $64M in FY01 to introduce electronic medical records
- $12M for automated order entry system for pharmaceuticals

**Investment in Improving Safety**