Experts Seek to Understand Epidemic of Medical Errors
A variety of experts agree on that point and want to open the reporting of medical errors to public inspection. State governments around the country are considering a mix of mandatory and voluntary error-reporting plans. The hope is that such reporting could help doctors learn from their errors without fear of reprisal, much in the way airline pilots do when they discuss close calls.
A former chairman of the American Hospital Association who attended the summit called for filling the gaps in patient-safety research. "As good as our systems are for preventing and reducing medical errors of all kinds, we can and must do better," said Gordon Sprenger, CEO of the Allina Health System in Minneapolis.
But the American Medical Association fears many doctors wouldn't come forward for fear of malpractice suits. "We don't think that mandatory reporting as it's been out there right now has worked very effectively," said the AMA's Timothy Flaherty, MD. Researching medical errors, Flaherty said, can only work if "it's confidential, non-punitive, and oriented to professional and organizational learning."
One of the most trouble-prone areas is dispensing drugs. Handwriting errors can be lethal. For instance, the term "u" for unit can be misread as a zero, thus increasing a dose of medication ten-fold. Computers could reduce that toll by half, but many hospitals still don't use such a system.
"Too often we've seen the same types of errors repeating themselves, and we know darn well that they're going to continue," said Michael Cohen, a pharmacist with the Institute for Safe Medication Practices.
Another patient-safety firewall could be an electronic medical record system, which in theory would be less error prone than paper. The Kaiser Permanente health maintenance organization is committing $1 billion to bring such a system to its 8 million patients throughout the country.
Researchers also plan to look at incentives to enhance safety, but it's not yet clear what form these might take. "Should we be punitive? Should we offer rewards? Is it regulations? Is it just disclosure of data? Again, it's untested ground," said Steve Wetzell, of the Leapfrog Group, a coalition that includes some of America's major corporations.
The IOM has recommended that $100 million be spent on medical errors research over the next three years. Currently, $50 million is pending in next year's federal budget for the U.S. Agency for Healthcare Research and Quality to study patient safety.
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