CLINTON-GORE ADMINISTRATION ANNOUNCES NEW ACTIONS TO IMPROVE PATIENT SAFETY AND ASSURE HEALTH CARE QUALITY
Goal to Reduce Preventable Medical Errors By 50 Percent Within Five Years
February 22, 2000
President Clinton today will receive a new report on medical errors from the Administration’s Quality Interagency Coordination Task Force (QuIC) and unveil a series of landmark initiatives to boost patient safety. These initiatives will help create an environment and a system in which providers, consumers, and private and public purchasers work to achieve the goal set by the Institute of Medicine (IOM) to cut preventable medical errors by 50 percent over five years.
Developed in response to the President’s call for action in December, the QuIC response endorses virtually every IOM recommendation proposed and includes actions that go beyond it. Consistent with the QuIC recommendations, the President will call for: a new Center for Patient Safety; a requirement that each of the over 6,000 hospitals participating in Medicare to have in place error reduction programs; new actions to improve the safety of medications, blood products, and medical devices; a mandatory reporting system in the 500 military hospitals and clinics serving over 8 million patients; and a phased-in nationwide state-based system of mandatory and voluntary error reporting. The President will also commend the Vice President for his leadership on this issue, thank members of Congress in both parties for their work, and praise the efforts of consumers, doctors, hospitals, nurses, health plans and businesses to improve patient safety.
PREVENTABLE MEDICAL ERRORS: A NATIONAL CHALLENGE. Although the U.S. offers some of the best health care in the world, the number of medical errors is still too high.
PRESIDENT UNVEILS NEW COMPREHENSIVE PLAN TO IMPROVE PATIENT SAFETY. Today, the President will announce the following new actions to assure patient safety:
A new Center for Quality Improvement and Patient Safety. Today, the President will announce that his FY 2001 budget includes $20 million, a 500 percent increase over last year’s funding level, to conduct research on medical errors reduction and create a new, IOM-recommended Center for Quality Improvement and Patient Safety. The Center will: fund research on patient safety; develop national goals for patient safety; issue an annual report on the state of patient safety; promote the translation of research findings into improved practices and policies; and educate the public.
The development of a regulation assuring that all hospitals participating in Medicare implement patient safety programs. This year, the Health Care Financing Administration will publish regulations requiring the over 6,000 hospitals participating in Medicare to have in place error reduction programs that include new systems to decrease medication errors. This action mirrors contractual requirements planned by the Federal Employees Health Benefits Plans and by many private sector purchasers. It also complements the voluntary efforts recently announced by the American Hospital Association.
The development of new standards to ensure that pharmaceuticals are packaged and marketed in a manner that promotes patient safety. Within one year, the Food and Drug Administration will develop new standards to help prevent medical errors caused by proprietary drug names and packaging that are easily confused with other those of other drugs. The agency will also develop new label standards that highlight common drug-drug interaction problems and other dosage errors related to medications. It will also implement a system that makes it possible to report serious adverse drug events on-line. The President is committing $33 million in the FY 2001 budget, a 65 percent increase over last year’s funding level, for medical error and adverse event reporting systems at FDA.
Modernized patient safety systems at the Department of Veterans Affairs and the Department of Defense to improve medication safety. The VA and DOD have been and continue to be leaders in the use of automated and other systems to reduce medical errors. The President will announce:
Comprehensive plans for a nationwide system of error reporting. Currently, 23 states (18 of which require hospital reporting) have reporting systems to track preventable medical errors and to help providers take corrective actions. Today the President will announce support for a nationwide system of error reporting -- one that will be state-based and phased in over time.
When fully implemented, this system will require mandatory reporting of preventable medical errors that cause serious injury or death, and will encourage voluntary reporting of other medical errors and "close calls." Information will be aggregated and made public (without identifying patients or individual health care professionals) to educate the public about the safety of their health systems. Both mandatory and voluntary reporting will enable providers to target widespread problems and develop the best preventive interventions. The Administration will take several actions to promote the importance of developing and using medical error reporting systems, including:
If all states have not implemented mandatory reporting systems within three years, the QuIC will deliver recommendations to the President that assure all health care institutions are reporting serious preventable adverse events. If research conducted by the Agency for Healthcare Research and Quality and other agencies indicates that the implementation of these systems does not enhance (or even detracts from) patient safety, the QuIC will modify its recommendations accordingly.
COMMENDS CONGRESS AND THE PRIVATE SECTOR FOR WORKING TO PROMOTE PATIENT SAFETY. Today, President Clinton noted the strong bipartisan interest in improving patient safety and that committees in the House and Senate held hearings to explore possible avenues to address this issue. The President noted that the Senate Appropriations and Health, Education, Labor, and Pensions (HELP) Committee will hold a joint hearing today, and have separately held several previously. He thanked the members of these Committees and other leaders in the Congress on this issue, including Senators Kennedy, Jeffords, Spector, Harkin, Dodd, Frist, Lieberman, Kerrey, Grassley, and several members of the House in both parties for their work. He also recognized and commended the ongoing work of the American Hospital Association, the American Medical Association, the American Nurses Association, and the Business Roundtable’s “Leapfrog Group”.
BUILDS ON THE CLINTON-GORE ADMINISTRATION’S LONGSTANDING COMMITMENT TO IMPROVING PATIENT SAFETY. In early 1997, the President established the Advisory Commission on Consumer Protection and Quality in the Health Care Industry (Quality Commission) and appointed Health and Human Services Secretary Shalala and Labor Secretary Herman as co-chairs. The Quality Commission released two seminal reports on patient protections and quality improvement. Subsequent to the Commission’s second report on patient safety and quality improvement, and consistent with its recommendations, the President established the Quality Interagency Coordination Task Force (QuIC), an umbrella organization also co-chaired by Secretary Shalala and Secretary Herman, to coordinate Administration efforts to improve quality. Also consistent with the Quality Commission’s recommendations, Vice President Gore launched the National Forum for Health Care Quality Measurement and Reporting. The “Quality Forum” is a broad-based, widely-representative private advisory body that develops standard quality measurement tools to help purchasers, providers, and consumers better evaluate and ensure the delivery of health care services. In addition to the work and significant potential of the QuIC and Quality Forum, other Federal agencies have made significant efforts to reduce medical errors and increase attention on patient safety. Last December, at the President’s direction, the Office of Personnel Management announced it will require all plans participating in the federal health program to implement error reduction and patient safety techniques.
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