MEDICAL MISTAKES

February 22, 2000
		Gwen Ifill leads a discussion on the president's proposed guidelines to reduce the number of medical mistakes, after a background report. The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.

Feb. 2, 2000: Trouble with Gene Therapy Nov. 30, 1999: Medical Mistakes The NewsHour's Health Spotlight. More NewsHour health coverage.   The American Hospital Association The Agency for Healthcare Research and Quality Institute of Medicine	GWEN IFILL: And joining me are Dr. John Eisenberg, director of the Agency for Health Care Research and Quality. The agency is part of the Clinton administration's Health and Human Services Department. And Carmela Coyle, senior vice president for Policy at the American Hospital Association, which represents 5,000 hospitals and health systems across the country. Carmela Coyle, the President says this is a good idea, that early reviews from Congress are encouraging for the President's proposal. What does the hospital association think? CARMELA COYLE, American Hospital Association: The president's proposal does contain some good ideas but also contain as number of unanswered questions that really need to be addressed to make certain that this is a prescription for patient safety. GWEN IFILL: What are those questions? CARMELA COYLE: Two of the critical questions have to do with the protection of and confidentiality of the information that's included in these reports. What's critical to the success of any error reporting system is the protection and the confidentiality of that information so that we can create an environment in which doctors and nurses and others feel comfortable talking about their mistakes -- so that we can learn from them and prevent those mistakes from happening again. GWEN IFILL: Dr. Eisenberg, what about the confidentiality concerns? DR. JOHN EISENBERG, Healthcare Research & Quality Agency: Well, Ms. Coyle is exactly right. It's critical when we have systems in place for learning from those errors that are made that clinicians and hospitals feel comfortable in reporting those errors and that the systems be confidential. In fact, we've gone so far as to suggest that the protections that exist in our peer review organizations, which are called peer review protections, be extended beyond those. GWEN IFILL: What are peer reviews? DR. JOHN EISENBERG: If a report has been assembled based on a hospital's experience in areas are other areas of quality and reported to another organization, that information is confidential and isn't to be disclosed unless it's disclosed in a very controlled way. We've proposed a limited number of serious events, as the president mentioned, death and serious adverse events, which would be the only ones that would be disclosed. The other events would be kept confident so the hospitals could learn from them. But we think it's critical that the public have access to the information that they need in order to be sure the health care system is safe for them.
	Assessing responsibility for mistakes
	GWEN IFILL: Well, the question I guess for me is how do you do that? It's nice you both agree a confidentiality is important for medical professions but what about -- I'm speaking for the patient here -- why shouldn't these people be held responsible, personally responsible for the mistakes they make? DR. JOHN EISENBERG: What's key about this initiative that we've proposed is that the solution to the errors problem is not to blame individuals, but to look for system solutions. The answers are going to be in systems because physicians don't practice by themselves anymore. Nurses don't practice by themselves. They practice in teams and the solutions are going to have to be solutions from those teams from systems. CARMELA COYLE: And the issue of discovery protections in a liability context and confidentiality are critical, because if those protections aren't there, we'll end up driving these errors underground. And what we want to do is bring them to the surface so we can learn from them. I think some the concerns we have with the current proposal is the language around these protections remains very vague. We're encouraged but we need to be certain that those discovery protections will, in fact, be in place while patients' names and the names of doctors and nurses involved will be kept confident confidential, the name of the hospital in which an error occurred will not be kept confidential. Our concern is some enterprising malpractice attorneys may be able to dig back through that information, identify caregivers and then we won't achieve the real objective, and that is understanding what happened and preventing it from happening again. GWEN IFILL: Is that a weakness - that this is a full employment act for liability lawyers? DR. JOHN EISENBERG: Absolutely not. In fact, I think what we'll see with this program is with the proper protections of the data, but disclosure of those very serious event, that the public will be protected, that the medical community will be able to learn from those errors and, in fact, the best protection against medical liability is to reduce the errors that cause the liability in the first place. We think this proposal will do just that. GWEN IFILL: Let's go back to what the president proposed today. He is urging states to impose mandatory reporting requirements within five years, saying that would cut the error rate by 50 percent, urging how -- what does that do and what happens if the states don't actually want to do it? DR. JOHN EISENBERG: We've proposed that we have a three-year period during which we work with the states and the hospital community, to develop the best programs that we can develop. But we evaluate them to see if the best practices are best, to learn how we can put these programs together in the most successful way. Then in three years we evaluate how the states are doing, the success of the reporting system and giving information to the public that's valuable and learning from it and then we give a report back to the president from this inner-agency coordinating task force to give advice about what should happen next. GWEN IFILL: Sounds like a lot of red tape that in the end doesn't take you necessarily where you want to go. DR. JOHN EISENBERG: It's a cautious approach because we understand that the public wants to know this information but we want to be sure that the information the public gets is accurate information. We think this is the right start -- a limited number of publicly disclosed events to start off and then to work with the states and others to find the best way of giving other information to the public. CARMELA COYLE: And one of the good ideas included in the president's proposal is one that would have the government's agency for health care research and quality actually take a look at the existing systems out there today, evaluate them and understand why they're under-used. We've got a number of reporting systems today, both voluntary and mandatory, and what we know is they're not used well. One of the reasons is because of this lack of discovery and confidentiality protections.
	Big problem, or perception problem?
	GWEN IFILL: Do hospitals actually think this is a big problem or is this a perception problem? CARMELA COYLE: This is a very serious problem and hospitals are taking that problem very seriously. We began work at the end of last year where hospitals across the United States have dedicated an initiative toward working specifically to prevent and reduce medication errors, which are one of the single largest causes and sources of medical errors in the United States. So we're serious about; it's an issue that must be addressed. GWEN IFILL: Dr. Eisenberg, there are about half a dozen states, which already imposed their own reporting requirements. Do you have any track record for them? Do you have any idea whether what you're suggesting they do has worked in the states which have already put it in place? DR. JOHN EISENBERG: We have a little information from almost 20 states that have mandatory programs in place now, and the early results from the research in that area shows that these programs can be successful in reducing errors and improving patient safety. GWEN IFILL: They can be but are they? DR. JOHN EISENBERG: Some of them are but in most cases we just don't have the research that tells us how successful they are and how they can be most successful. That's one of our plans is to work with the states, find out what works best and then disseminate that throughout the country. GWEN IFILL: One of the things that this report says that doctors will now be asked to report is not only medical errors but also near-misses. What's a near-miss and how do you report one? CARMELA COYLE: I think it's important to understand the distinctions in medical errors. There are those errors that result in serious harm or death of a patient. There are other adverse events, and then there are the so-called close calls where a mistake may have been made, but it did not result in any noticeable impact on the patient. It's critical that we begin to create reporting systems and encourage the voluntary reporting of those close calls because while it may have been a close call this time, we want to capture that, learn from it and prevent it from becoming a serious event in the future. GWEN IFILL: And what is the incentive for the physician to report a close call when everything turned out fine? DR. JOHN EISENBERG: Professionalism and the desire to do better and earn for future patients. What we think we can put together is a system of reporting that helps professionals and their patients do a better job of improving patient safety. GWEN IFILL: Presume for a moment that the president's plan is not the beyond end all of this. What would you suggest as an alternative to address what you say is a very big problem? CARMELA COYLE: Unfortunately Washington has oversimplified this issue into one of voluntary versus mandatory reporting, and the issue is much more complex than that. We think at the core of a successful system is this notion of protecting the information so caregivers feel comfortable talking about mistakes so we can learn from them. We also think that Washington has been focused on external reporting systems to outside organizations. There's a lot that can be done within healthcare organizations today, making certain that not only do we have systems in place to capture mistakes when they occur, but that we can share best practices of what are the components of those systems that really are most effective, share that across the United States and improve the learning from those mistakes into the future? GWEN IFILL: Okay. The gauntlet is thrown to you then, doctor. What exactly -- why can't the government step out of it and trust hospitals to fix this problem on their own? DR. JOHN EISENBERG: We trust the hospitals that they'll do what they can. We think we can work together with the hospitals. And, in fact, the initiative that the president proposed today is a multifaceted one with every part of the government that's involved in healthcare quality, the Food and Drug Administration, the Defense Department, the Veterans Affairs, all working together with the hospital industry to see what we can do together to improve patient safety.
	Real improvements?
	GWEN IFILL: If we don't know whether this has worked in the past and there is some disagreement about how this will work in the present, how do we know that we are actually doing anything to improve patient safety? DR. JOHN EISENBERG: One thing we do know is that there are certain patient safety practices which have been demonstrated to work. They've been demonstrated to decrease errors and improve patient quality. And we've asked in the Health Care Financing Administration, which is part of the Department of Health and Human Services and runs the Medicare program, they're going to ask every hospital to have a patient safety program in place, that will be part of what they ask every hospital to do to participate in the Medicare program. And we expect the hospital industry will want to collaborate for us so that we can stimulate every hospital to put those patient safety programs in place, but not just that, to let the patients know which patient safety programs those hospitals do have in place. CARMELA COYLE: And one of the things that we've already done is o send a series of successful practices, lists of things that are known to actually reduce and prevent errors to all 5,000 hospitals and health systems in the United States and to encourage them to use those practices. I think at its core what's really going to drive a patient's safety is when a doctor or a nurse comes to work everyday, they're coming there to help patients. They're coming there to care and to cure. When they make mistakes, it's a devastating experience for them, and it's part of this concept of professionalism. They have don't want those mistakes to happen. GWEN IFILL: There is bipartisan legislation working its way through Congress that would address some of these issues. Is it something you would support? CARMELA COYLE: The proposal that will ultimately come out of this I think we have yet to see. The president has a proposal on the table. There are a number of congressional proposals that are on the table and others that will be developed. GWEN IFILL: Will any of them suit you? CARMELA COYLE: I think most certainly. I think if the critical issue is addressed and that is ensuring the protection of this information and the confidentiality of the information so doctors and nurses feel comfortable talking about mistakes. GWEN IFILL: Is there anything on the hill you can see yourself working with? DR. JOHN EISENBERG: I testified this morning before a joint meeting of the Senate Health Appropriations Committee and the Health, Education, Labor and Pensions Committee, and I was very impressed by the bipartisan commitment on both of those committees to do a good job of responding to the Institute of Medicine report. And I think the same kind of commitment is in the House of Representatives. We're going to look very carefully at the legislation that's proposed. GWEN IFILL: John Eisenberg and Carmela Coyle, thank you both very much.