Hospitals should be required to report certain medical errors to publicly accessible, state-run databases to create a level of accountability now lacking in the healthcare system, the National Quality Forum recommended in a report released last week.
The forum is a private, not-for-profit organization established by President Clinton to set a national agenda for healthcare quality. Because of its legal standing, the forum's recommendations could be quickly adopted by Medicare.
In its report, the forum's steering committee recommended that 27 events, including patient deaths from contaminated drugs, operations on the wrong body part and severe pressure ulcers, be routinely tracked by states. The list of what the NQF calls "never events," or events that should never occur in a hospital, would provide a standard for states to use in refining or developing systems for collecting adverse medical-event information.
Fifteen states mandate reporting of such events, and six have voluntary reporting programs.
A network of comparable state systems would allow for the first time national tracking and monitoring of medical errors, said Kenneth Kizer, M.D., president and chief executive officer of the NQF.
"The presumption is that these are rare events, but the reality is that we really don't know," Kizer said.
In a 1999 report To Err is Human, the Institute of Medicine said that as many as 98,000 Americans die each year from medical errors in hospitals.
Conceivably, reporting of adverse events to state databases could be part of Medicare's conditions of participation for hospitals, Kizer said. And large purchasers, such as those in the Leapfrog Group, might make reporting of events a standard used to help select hospital providers (See special report, p. 30).
Identifying individual institutions at which the adverse events occurred is a critical component of public accountability in the steering committee's view. Public disclosure, however, would not extend to the identities of individual practitioners.
"If a plane goes down, you'd like to know more than the fact that a plane went down. You'd also like to know if it was United or Delta or Continental," Kizer explained. "Certainly, if a whole lot of planes are going down, you'd want to know that information."
Yet, even when providers and health plans are required to report unflattering data to a central repository, many find a way around the reporting requirements, according to a separate report released last week by HHS' inspector general's office (See story, p. 6).
Kizer said he is a firm believer in the need for a nonpunitive environment to encourage error-reporting and broad participation in analyses of errors.
In addition to the relatively narrow scope of mandatory public reporting recommended in the report, voluntary, confidential reporting systems are desperately needed to track "thousands of other things," Kizer said.
The Joint Commission on Accreditation of Healthcare Organizations implemented a "sentinel event" policy in 1996 to collect information about medical errors at hospitals, but Kizer said the policy isn't sufficient. "We know that that information is underreported and it doesn't include a lot of other settings where events happen as well," Kizer said.
The forum's governing board includes a top HCFA official, other federal health agency heads, and hospital and employer representatives, among others.