Although hospitals and doctors have been committing them for decades, medical mistakes have become the healthcare topic du jour in Washington, with special-interest groups and lawmakers crawling over one another for the political high ground as various groups promise to do something about the problem.
Next year they might.
Enjoying the scrimmage from the sidelines was this year's tackling dummy, the managed-care industry, which lost its fight against patient-protection legislation.
"Physicians and other types of providers have to be accountable. I think they've managed to escape that to date," said Charles Cutler, M.D., chief medical officer for the American Association of Health Plans. "All along, I think people in managed care thought that (improving healthcare quality) is a shared responsibility. (But) the expectations of improving healthcare have been put totally on the health plans."
What lit the fuse was an Institute of Medicine report released late last month that said errors in patient care kill as many as 98,000 in the U.S. every year (Dec. 6, p. 16). It urged Congress to require providers to report medical errors and to establish a center for patient safety to track those reports (See chart, p. 3).
The self-initiated IOM report was the main product of an IOM council examination of healthcare quality in the U.S. The council began its work in September 1998. This report is the first of several.
For its statistics on medical errors, the council relied on research dating to the early 1990s. Among the work it examined was that of Lucian Leape, a Harvard School of Public Health professor and one of the foremost experts on medical errors, who also was a member of the IOM committee that wrote the recent report.
Although healthcare quality experts immediately dismissed the report as nothing new, the news struck a chord with the media, the public and lawmakers hungry for an issue they could use to ease their constituents' fears about healthcare quality.
"There hasn't been one trigger report up to this point," said Mary Wakefield, a registered nurse, a professor of health policy at George Mason University in Fairfax, Va., and a member of the IOM committee that wrote the report. "The source (of the report) was important. The IOM is perceived as objective, and when they speak on a topic, people tend to listen. And (the report) was much more targeted on medical errors than previous reports, which were like pre-shocks to an earthquake."
While provider groups like the American Hospital Association and the American Medical Association were aware that the IOM report was in the works, they were caught off-guard by an unannounced early release date. The scheduled release was January, moved up because the report was done and the organization believed the findings would leak to the press, said IOM spokeswoman Susan Turner-Lowe.
The unexpectedly strong reaction to the report sent doctors, hospitals and their national associations into immediate spin control, arguing that they're on the same page as the IOM.
The day after the report's release, the Joint Commission on Accreditation of Healthcare Organizations issued a statement applauding the IOM for building on the work of the commission and other quality experts. The Joint Commission provided information to the IOM for its report.
"As the nation's leading evaluator of healthcare quality, the Joint Commission has long been committed to finding better methods to reduce and prevent medical errors," the statement said.
That same day, the AMA issued a statement under the letterhead of its National Patient Safety Foundation, formed in 1997 after a spate of very public patient deaths across the country tarnished physicians' image.
Like the JCAHO, the foundation proclaimed "strong support" for the report's findings and touted its own work on patient safety, including providing information to the IOM for the report. It also downplayed the frequency of medical errors.
"In general, medicine is very safe, but it is also very complex and is not without risk," Nancy Dickey, M.D., a past president of the AMA, said in the foundation's statement.
The AHA in its Nov. 29 statement also glossed over what the IOM called a "fundamentally unacceptable" number of medical errors.
"Medicine is delivered by people who are highly trained and receive continuous education to stay on top of their respective areas of discipline," the AHA statement said. "Further, hospitals and caregivers comply with strict quality- control procedures in addition to federal, state, local and independent oversight."
However, the AHA waited a week after the report's release to announce a partnership with the Institute for Safe Medication Practices to reduce the number of medication errors that occur in the nation's hospitals.
Many of the same groups making statements for years have been suppressing public and private efforts to measure and report the quality of care provided by hospitals and doctors while at the same time periodically announcing new initiatives to do just that.
For example, the AMA's National Patient Safety Foundation has awarded several grants for researching the quality of care and conducted seminars with health quality experts, but much of its work has been invisible to patients.
But the game of promising something and delivering nothing seems to have finally caught up with providers, especially on Capitol Hill.
Senate Republicans, for one, received the IOM report warmly. Angered by the AMA's alliance with Democrats in pushing for a patient "bill of rights" that includes the right to sue health plans, the Senate GOP sees an opportunity to turn the tables.
"I don't see how you pass a patient- protection bill without addressing medical errors," said a Senate Republican aide who asked not to be identified. "What is the best patient protection? Maybe it's to come out of the hospital alive."
Sen. Arlen Specter (R-Pa.), chairman of the Senate Appropriations HHS subcommittee, jumped to the front of the parade last week, holding the first congressional hearing on medical errors since the IOM report came out.
"I think we can construct a format for reporting and disseminating information (on medical errors)," Specter said. "I would respectfully disagree with the AMA about the need for mandatory reporting. The evidence is on the table.
"We've got a good document here (in the IOM report), and now we want to push the envelope."
The IOM report scored points with Democrats, too.
Sen. Edward Kennedy (D-Mass.), ranking Democrat on the Senate Health and Education Committee, said he would introduce legislation to help reduce the number of medical errors when Congress reconvenes in January.
Like the AHA, President Clinton waited a week after the report's release to make his own splash, signing an executive memorandum Dec. 7 that requires federal agencies to work together to review the IOM report and return their recommendations to the White House by early February (Dec. 13, p. 3). Clinton also wants to spend more federal dollars on researching medical errors.
What's creating the most fear among providers is the real possibility that the government will follow through on the IOM's recommendations that the reporting of medical mistakes be mandatory.
"From our perspective, we thought mandatory reporting was very important," said the IOM's Wakefield, also a member of the Medicare Payment Advisory Committee, which examined medical errors under Medicare in its June report to Congress. "It will help hold the healthcare systems accountable."
"There ought to be a place in the government responsible for analyzing data that is focused on research but not separate from the rest of the (quality) agenda," said John Eisenberg, M.D., administrator of the federal Agency for Healthcare Research and Quality, which would likely house the proposed center for patient safety.
Richard Wade, senior adviser for communications at the AHA, warned against allowing a mandatory reporting system to become "a tool for malpractice attorneys."
Said the AMA's Dickey, "We have serious concerns with this approach, because past efforts have had such a negative impact."
Patient advocates say that the current system of confidential reporting-from Medicare peer review organizations to voluntary "sentinel event" reporting to the Joint Commission-has had little effect on quality improvement and gives patients no information on which to base their choice of provider.
"After more than 15 years of confidentiality designed to encourage reporting, the system is still a scofflaw," said Ray McEachern, president of the Association for Responsible Medicine in Tampa, Fla., a patient advocacy group that supports public reporting of errors.
Also supporting mandatory reporting is the American Nurses Association, which has accused hospitals of putting financial interests, including cutting nursing positions, ahead of patient safety.
Politically, the ANA's endorsement is important, Wakefield said.
Dennis O'Leary, M.D., the Joint Commission's president, said the report indicated not so much the failure of self-policing but "the failure of American society. If you have a society built on blame and punishment whenever something goes wrong, there will be fear of reporting."
O'Leary said the JCAHO is planning once again to push legislation that would protect hospitals and practitioners from liability if they disclose information about medical errors for quality- improvement purposes.
The publicity generated by the IOM's report may make it impossible for providers to simply say no to a national reporting system, Wade said.
"The worst criticism we will get is if we start to head down the road and do nothing," Wade said.
"The worst thing to happen would be for the public to find out in a year that we had all this flurry on some sort of cohesive national effort to reduce medical errors, and it all fell apart."