June 28, 2001 (Washington) -- Hospitals must either tell patients they have sustained treatment-related injuries or risk losing what amounts to their Good Housekeeping seal of approval. Starting on July 1, new standards will go into effect that are intended to promote openness and safety in 5,000 of the nation's hospitals.
The rules have been developed by the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, which sets quality standards for the industry. The driving force behind the tough new notification requirement is a report issued by the highly regarded Institute of Medicine, or IOM, in 1999. That analysis concluded that between 44,000 to 98,000 deaths annually could be attributed to medical error.
Dennis O'Leary, JCAHO's president, says those involved in healthcare must "radically change their thinking about medical mistakes. We need to create a culture of safety in hospitals ... in which errors are openly discussed and studied so that solutions can be found and put in place."
Who should handle the tough task of explaining that a mistake was made? "I really expect the responsible physicians to be out on the line talking to patients," says O'Leary.
The new policy takes effect on July 1, and those hospitals that don't comply could eventually lose their accreditation. While the Joint Commission has had a voluntary system in place for six years, O'Leary says it's seeing just a tiny fraction of the errors in the system.
"What is really going on is not that organizations are not reporting to us. These incidents are not even being reported internally. People are frightened," says O'Leary.
The new program's goal is to create a climate where healthcare professionals can report their mishaps without blame or shame. "If you fire every caregiver who made a mistake or an error, pretty soon you won't have anybody left, because everybody does make mistakes," said O'Leary during a conference call with reporters. The error information itself will not be released to the general public, but patients and their families should expect a prompt accounting, says O'Leary, not an impersonal letter from an administrator.
The Joint Commission describes an error as, "an unintended act, either of omission or commission, or an act that does not achieve its intended outcome."
Some of the errors can be attributed to straightforward issues like misinterpreting a doctor's handwriting or giving the wrong medications to a patient. Others have to do with the system's problems and faulty teamwork, which O'Leary says could be largely corrected by adopting the teamwork approach used in the airline industry.
Lonnie Bristow, MD, former president of the American Medical Association, helped write the IOM report. He tells WebMD he is pleased with the new rules and calls for continued vigilance to recognize mistakes, to assure they don't happen again. The rules are fine "as long as you continue to go after who [made a mistake]," he says, "[because] you can bet your boots it's going to happen again to some other 'who,' at some other point in time."
Don Nielsen, MD, senior vice president for quality leadership of the American Hospital Association also supports the JCAHO policy. "It reflects what we've been doing with our members for the past two years around a culture of safety ... and by trying to avoid errors by trying to identify where there are weak points in the system," he tells WebMD.