[Congressional Record Volume 146, Number 75 (Thursday, June 15, 2000)]
[Senate]
[Page S5262]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. JEFFORDS (for himself, Mr. Frist, and Mr. Enzi):
  S. 2738. A bill to amend the Public Health Service Act to reduce 
medical mistakes and medication-related errors; to the Committee on 
Health, Education, Labor, and Pensions.


              the patient safety and errors reduction act

  Mr. JEFFORDS. Mr. President, I am pleased to join today with my good 
friend Senator Frist to announce the introduction of the Patient Safety 
and Errors Reduction Act, a bill which will work toward increasing 
patient safety for all Americans.
  Late last year, the Institute of Medicine (IOM) released a report 
citing medical errors as the eighth leading cause of death in the 
United States, with as many as 98,000 people dying as a result each 
year. More people die of medical mistakes than from motor vehicle 
accidents, AIDS, or breast cancer. The IOM report took a serious look 
at the problem of medical errors and provided some thoughtful 
recommendations for change.
  Last year I worked closely with Senator Frist to ensure that Congress 
pass Senate Bill 580, the Healthcare Research and Quality Act of 1999. 
This newly passed legislation reauthorized by the Agency for Health 
Care Policy and Research, renamed it the Agency for Healthcare Research 
and Quality (AHRQ), and refocused its mission to support healthcare 
research on safety and quality improvement. I am pleased that AHRQ has 
decided to dedicate more than $20 million for research on medical error 
reduction. This shows a real commitment by Dr. John Eisenberg and his 
agency to address the problem of medical errors.
  Our bill will attack this problem in several ways. First, it will 
provide a framework of support for the numerous efforts that are 
already underway in the public and the private sectors. Second, it will 
establish a Center for Quality Improvement and Patient Safety within 
the Agency for Healthcare Research and Quality. And finally, it will 
provide needed confidentiality protections for medical error reporting 
systems.
  I believe we can save thousands of lives by substantially reducing 
medical mistakes over the next few years. We have a great opportunity 
to apply the safety lessons that we have already learned--both within 
health care and in other fields.
  How can we prevent these mistakes? One lesson we have learned that 
was repeated time and again in our hearings is that mandatory reporting 
of all errors and subsequent punishment of healthcare professionals 
doesn't work very well.
  Even good doctors and nurses make mistakes during the most routine of 
tasks. Clearly, the root cause of medical errors is more systemic. 
Medicine has some of the most advanced technology for treating patients 
and some of the most rudimentary systems for ensuring quality. Taking a 
look at the systems that ensure patient safety will go farther in 
addressing the problem of medical errors rather than reprimanding any 
one individual or group.
  Over the past few decades we have seen one industry after another 
adopt the principles of continuous quality improvement. The government 
itself has instituted these principles, notably in its regulation of 
aviation. Focusing on punishment will only deter improvement.
  Having said that, we are not interested in sweeping problems under 
the rug, but bringing them out into the open. And if an individual is 
harmed, this bill in no way limits the legal recourse that patients 
have now. The confidentiality protections are just for information that 
is submitted under quality improvement and medical error reporting 
systems. Patients and their lawyers will still have access to the 
entire medical record just like they do now.
  Our bill also creates a new center for patient safety through AHRQ as 
the IOM report recommended. This Center will collect information on 
medical errors and serve as a center to develop strategies to reduce 
them. It is likely that additional funding beyond the $20 million 
recommended by the President will be needed for AHRQ's new role 
overseeing this center for patient safety.
  We also need to allow for confidentiality--through peer review 
protections--for information that is voluntarily submitted regarding 
medical errors. This legislation provides for these protections.
  Once the information is collected and analyzed, either through AHRQ 
or another deemed institution, such as the Vermont Program for Quality 
in Health Care, recommendations on ways to prevent errors need to be 
developed and disseminated throughout the health care industry.
  It is my hope that these recommendations will continue to be 
incorporated into survey instruments by organizations such as the Joint 
Commission on Accreditation of Healthcare Organizations, the 
accrediting body responsible for hospitals and other inpatient 
healthcare settings. In this way, the health care industry can engage 
in the kind of continuous quality improvement that is vital to curbing 
errors and saving lives. But a medical errors program will only succeed 
if hospitals, doctors and other health professionals support it and 
participate in it willingly.
  Neither the IOM nor Congress discovered this problem. Health care 
professionals have been at work for some time in trying to address 
medical errors. I hope that by becoming a partner in this process, the 
federal government can accelerate the pace of reform and provide the 
most effective structure possible.
  I am pleased that our legislation has the support of many, including 
the United States Pharmacopeia, the American Hospital Association, the 
American Health Quality Association, the American College of 
Physicians/American Society of Internal Medicine, the American 
Psychological Association, and the Institute for Safe Medication 
Practices.
  Mr. President, we cannot afford to wait on this issue. This 
legislation will raise the quality of health care delivered by 
decreasing medical errors and increasing patient safety and I will work 
to ensure its enactment this year.
                                 ______