[Congressional Record Volume 148, Number 56 (Tuesday, May 7, 2002)]
[Extensions of Remarks]
[Page E726]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                MEDICATION ERROR PREVENTION ACT OF 2002

                                 ______
                                 

                       HON. CONSTANCE A. MORELLA

                              of maryland

                    in the house of representatives

                          Tuesday, May 7, 2002

  Mrs. MORELLA. Mr. Speaker, in late 1999, the Institute of Medicine 
(IOM) issued a major report on medical mistakes entitled ``To Err Is 
Human: Building a Safer Health Care System.'' This eye-opening study 
found that errors by health care professionals may result in the deaths 
of between 44,000 and 98,000 people in the United States every year, 
and injure countless others. Shockingly, more people die from avoidable 
medical errors each year than from highway accidents, breast cancer, or 
AIDS.
  Congress reacted swiftly to the IOM report. Some members of the House 
and Senate, including myself, introduced bills to implement the 
report's recommendations, and hearings on medical errors were held in 
various committees. But Congress sometimes has a short attention span. 
Despite the flurry of activity at the beginning of 2000, by the close 
of the session other health care debates had crowded out the medical 
error issue and no further action was taken on medical errors.
  We cannot let another year go by without doing something about 
medical errors; therefore, I am reintroducing a medical errors bill and 
this time I plan to see it through to enactment. If the IOM estimate of 
the fatalities that result from medical errors is remotely close to 
accurate, Congress cannot wait another year to act.
  According to the IOM, most medical errors do not result from 
individual recklessness, but from basic flaws in the way hospitals and 
other health care systems are organized. For example, deadly mistakes 
have resulted from stocking the patient-care units in hospitals with 
certain full-strength drugs that are toxic unless diluted. Confusion 
over similarly-named drugs is another major cause of medical mistakes: 
studies have shown, for instance, that confusion over the similarly-
named drugs ``Cefuroxime'' and ``Cefotaxime'' accounted for numerous 
errors in the administration of these drugs.
  Other errors result from the increased complexity and specialization 
of health care treatment. When a patient is treated by different 
doctors for different ailments, a particular practitioner may not have 
complete information about all treatments the patient is receiving, and 
may prescribe medication that is incompatible with other medications 
the patient is taking.
  In recommending ways to reduce errors, the IOM focused on the need to 
encourage efficient and comprehensive reporting systems so that health 
care professionals can benefit from the experiences and ``best 
practices'' of their colleagues. Other sectors of the American economy 
have established coordinated safety programs that collect and analyze 
accident trends--such programs are commonplace, for example, in the 
transportation field. Yet there are few centralized systems for 
gathering and disseminating information on medical errors. For this 
reason, in my legislation, I specifically advocate for the use of 
MedMARx--a national, Internet-accessible reporting system designed to 
reduce medication errors in hospitals. This system allows hospitals to 
anonymously and voluntarily report, track, and monitor their medication 
errors, to identify trends, and to pinpoint problem areas. In order for 
systems like MedMARx to become successful though, participating 
hospitals and health care professionals must know that they can report 
problems encountered in clinical practice without endangering their 
careers. But according to the IOM, a major obstacle to the full 
implementation of medical error reporting programs is the threat that 
the reports themselves will be disclosed in civil litigation.
  Naturally, hospitals are reluctant to generate documents that will be 
used against them in adversarial proceedings, so IOM called for 
enactment of an evidentiary privilege in federal law against the 
disclosure of information provided to medical error reporting systems. 
In the legislation, I would protect the confidentiality of data on 
medical mistakes where the information is collected and analyzed solely 
for the purpose of improving safety and quality. Without this 
protection, hospitals and health care professionals fear that 
information reported might ultimately be subpoenaed and used in 
lawsuits against them, thereby discouraging their participation.
  The time to act is now. Patients are literally killed by medical 
errors every day, yet Congress has not done anything to ensure that the 
IOM recommendations that could significantly reduce these tragic 
mistakes are signed into law. Working together, we can reduce medical 
errors and improve the quality of patient care in the United States.

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