ANNAPOLIS – With deaths nationwide from preventable medical errors outpacing the number of people who die annually from AIDS or highway accidents, two Baltimore delegates are working to address the problem in Maryland.
Delegates Brian K. McHale, D-Baltimore, and Peter Hammen, D-Baltimore, have drafted a bill to require the Maryland Health Care Commission develop a plan aimed at reducing preventable medical errors in the state.
The Patients’ Safety Act of 2001 would mandate all medical errors be reported to certain General Assembly committees. It also would encourage health care practitioners to voluntarily report their mistakes.
Because the bill was submitted after the Feb. 9 bill introduction deadline, it must go to the House Rules and Executive Nominations Committee before it may be assigned to a committee.
“I don’t have much confidence in issues like this being handled on the federal level,” McHale said. “This is something we should get out front rather than wait on the federal government.”
Hospital medical errors are the eighth leading cause of death, according to a November 1999 report issued by the National Academy of Sciences’ Institute of Medicine. Each year, between 44,000 and 98,000 people die in U.S. hospitals from medical errors made by clinicians and physicians, the report showed.
That number does not include mistakes made in pharmacies, urgent care centers, outpatient clinics, physicians’ offices and nursing homes. Medication errors alone are responsible for 7,000 deaths annually – 16 percent more deaths than the number attributable to work-related injuries.
“This has been a problem that has always been with us,” said Dr. Gregg Meyer, director of the Center for Quality Improvement and Patient Safety in Rockville. “You have a case where there is a new recognition. In medical errors and patient safety these things are happening and taking a greater and similar toll in terms of the impact on the public.”
The center is spending $25 million to investigate the value of safety reporting. Twenty-one states have a mandatory reporting requirement. The proposed bill includes mandatory and voluntary reporting of all medical errors with provisions for maintaining confidentiality.
“We find out these incidents from medical malpractice suits,” McHale said. “If we can develop a voluntary confidential reporting system, than hopefully you would have hospitals say, `We had this adverse encounter. We did an analysis and determined it was caused by and for these reasons.'”
Dr. Peter Pronovost, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University Medical School, said the problem with mandatory reporting is that “it drives reporting underground.” However, he said states with medical reporting are able to describe the improvements in safety they have made.
“There has to be freedom from liability,” said Pronovost. “The literature has said most errors don’t result in a bad outcome. But getting knowledge of those errors can improve the system that we work in.”
Flaws in the health care system cause most of the errors, not incompetence by health care practitioners, the institute reported.
Meyer said the focus should be on improving the system. For example, he said the key to reducing prescription mishaps is not to get doctors to take a handwriting class, but to get them to use computerized entry systems.
“There is a science that studies safety and what the science tells us clearly is that the underlying system is at the root of the problem,” Meyer said. “I don’t think the problem is individuals not taking culpability for their actions.”
The computerized entry prescription system is just one of the types of programs McHale hopes the Maryland Health Care Commission will develop. He is also sponsoring a bill requiring pharmacies to report to patients, health care providers and the Board of Pharmacy any error they make in dispensing or labeling a prescription.
After the release of the institute’s report, former President Clinton ordered the Quality Interagency Coordination Task Force to make recommendations on how to increase patient safety. He also announced a plan to require states have a national mandatory reporting system. So far, President Bush has made no mention of continuing Clinton’s plans. But individual states and hospitals are developing their own patient safety programs.
“It (this issue) involves patients, providers, health care workers and policy makers,” Meyer said. “If we don’t all work together on this, we’re not going to make the progress that we can or that we should.”