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The Institute of Medicine report on the toll medical errors take stands like a monolith in front of every provider, payer, patient, and state. The figures are by now familiar: An estimated 2.9% to 3.7% of hospital admissions end up with an adverse event, with as many as 98,000 deaths per year. The cost is estimated to be a whopping $17 billion to $29 billion.
To Jan Malcolm, commissioner of health with the Minnesota Department of Health in St. Paul, the debate over the accuracy or inaccuracy of these numbers is a sideshow. One of the very real problems is that there is such a heated debate over the numbers instead of more debate about system changes by states, she says. Many states have stepped into the breach to staunch the flow of bad numbers. Coordinators among the states realize they are not working alone, that other states are constructing systems of their own to help, as is the federal government. She says her state created the Minnesota Alliance for Patient Safety, joined the National Quality Forum, and commissioned a study on the factors influencing patient safety and patient care. States are responsible for holding providers accountable for safety, should provide clear performance standards, and should educate everyone about medical errors and safety, she contends.
Nancy Ridley, assistant commissioner of the Massachusetts Depart-ment of Public Health, wants to eliminate regulatory overlap and end up with a single system to prevent medical errors. One of her main concerns is that national legislation could overwrite state rules.
The Massachusetts Medical Error Coalition has taken several steps to eliminate errors. It has developed a consumer pamphlet regarding medical errors, held leadership forums, spawned coalition member initiatives, extended its media outreach, and hired an executive director. The state has set up reporting and investigation systems: one for hospitals and one for nursing homes. In hospitals, the most serious errors must be immediately reported by telephone; all others must be reported in writing within seven days. Reports become public after the investigation is completed.
Richard Lee, deputy secretary of quality assurance with the Pennsylvania Department of Health in Harrisburg, says reducing errors requires better communication between the board of health and other health care departments. Helping determine the number of medical errors and how they occur can be done by checking hospital records and looking at the discharge codes. "ICD-9 cards will give a guide to finding errors in your state," Mr. Lee advises.
Pennsylvania would like to have a separate reporting system for near-misses, he added. "There seem to be a tremendous number of hospitals that are underreporting. I can’t believe they are not having problems."
While New York state has a mandatory reporting system, according to Robert Barnett, director of the Patient Safety Center at the New York State Department of Health in Delmar, there is underreporting to the state, he says. "Should the state have a role in near-miss situations? We’re struggling with this."
New York’s Patient Occurrence Reporting and Tracking System (NYPORTS) is the state’s mandatory adverse-event reporting system. It is a Internet-based system that began in 1995. Hospitals can use it to get feedback on their own reporting patterns and compare them with other hospitals in the region and state. One of the challenges to reducing medical errors and improving patient safety, according to Mr. Lee, is to provide leadership in developing best practices and tools for patient safety and to be sure to include industry experts in the effort.