[Congressional Record Volume 148, Number 127 (Wednesday, October 2, 2002)]
[Senate]
[Pages S9848-S9849]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. KENNEDY:
  S. 3029. A bill to amend title IX of the Public Health Service Act to 
provide for the improvement of patient safety and to reduce the 
incidence of accidental medical injury; to the Committee on Health, 
Education, Labor, and Pensions.
  Mr. KENNEDY. Mr. President, I am pleased to introduce today ``The 
Patient Safety Improvement and Medical Injury Reduction Act.'' This 
legislation will protect patients and save lives. It will do more for 
public health than a breakthrough new drug or a new therapy for deadly 
disease. The bill does this by providing a comprehensive plan to 
greatly reduce medical errors, promote a culture of greater patient 
safety and provider accountability, and improve the quality of medical 
care in the United States.
  As the Institute of Medicine, IOM, concluded in its landmark 1999 
study, medical errors kill up to 98,000 people in U.S. hospitals every 
year. That means that more Americans die from medical mistakes each 
year than from AIDS, breast cancer or highway accidents. In fact, each 
day, more than 250 people die because of medical mistakes, the 
equivalent of a major airplane crash every day.
  Other studies support the IOM's shocking conclusions.
  A Commonwealth Fund survey this year found that 22 percent of 
respondents reported that they or a family member had experienced a 
medical error of some kind. About 10 percent reported that they or a 
family member grew sicker as a result of a mistake made at a doctor's 
office or in a hospital, and 16 percent were given the wrong medication 
or wrong dose when filling a prescription at a pharmacy or while 
hospitalized.
  A study published September 9 by the Archives of Internal Medicine 
also concluded that medication errors occur in one of every five does 
administered to hospital patients. The magnitude of these costly and 
life-threatening mistakes is astonishing, and calls for immediate 
improvement.
  We can and should do better for our citizens. Americans deserve the 
highest quality health care, yet these errors put everyone at risk of 
unnecessary harm. This legislation raises patient safety to the 
national priority it deserves, and assures America's patients that they 
can expect high quality health care when they are sick or injured.
  To accomplish this goal, or legislation requires comprehensive 
action. The IOM concluded that improvements will require sweeping, 
systemic changes in our health care system. IOM made numerous, sensible 
recommendations, which are fully addressed by the Patient Safety 
Improvement and Medical Injury Reduction Act.
  The overwhelming majority of errors are caused by flaws in the health 
care system, not the outright negligence of individual doctors and 
nurses. Our hospitals, doctors, nurses, and other health care providers 
want to do the right thing. The bill gives the health care community 
the tools to identify the causes of medical errors, the resources to 
develop strategies to prevent them, and the encouragement to implement 
those solutions.
  A key concern addressed by this legislation is to allow doctors and 
other health professionals to share information regarding best 
practices and lessons learned from their mistakes without fear of 
winding up in court. At the same time, medical professionals and 
hospitals that injure patients through their negligence should still be 
held accountable in court, just as they are today.
  To balance these competing concerns, our legislation allows reports 
and analyses created under a new system of information-sharing between 
providers, patient safety organizations and a newly established 
National Patient Safety Database, to be immune from legal discovery. 
Health care professionals who submit reports to the programs would also 
be protected against discrimination in the workplace for participating 
in the reporting systems.
  By the same token, however, this new system will not become a shield 
to hide medical negligence. As a result, this legislation continues 
current law when it comes to those elements of patients' medical 
records that have nothing to do with the patient safety improvements 
contemplated by the Act. Nor would the privilege apply to such 
information merely because it is reported to a patient safety 
organization or the National Patient Safety Database. Just as 
importantly, the new privilege would not affect compliance with State 
accountability systems.

[[Page S9849]]

  Consistent with the IOM recommendations, the Act also creates a new 
Center for Quality Improvement and Patient Safety in the Agency for 
Healthcare Research and Quality to promote patient safety. The Center 
would conduct and support research on medical errors, certify learning-
based patient safety organizations around the country, administer the 
voluntary National Patient Safety Database, and disseminate evidence-
based practices and other error reduction and prevention strategies to 
health care providers, purchasers and the public. Reports submitted 
would be analyzed to identify systemic faults that led to the errors 
and solutions to prevent future similar errors. The Act would also 
create a ``learning laboratory'' under the Center for focused study of 
errors and their correction in select health care facilities.
  The IOM also highlighted medication errors as a ``high priority area 
for all health care organizations'' and recommended the use of 
computerized physician order entry systems and advanced prescribing 
software to screen for inappropriate doses, allergies, and drug 
interactions. The Act would provide funding and uniform standards for 
the implementation of such systems, as well as grants for community 
partnerships for health care improvement.
  As widespread and serious as the problem of medical errors is, it can 
be solved by a national commitment of resolve and resources. 
Improvements are clearly possible. The field of anesthesia undertook 
such an effort almost twenty years ago. Today, the number of fatalities 
from errors in administering anesthesia has dropped 98 percent.
  Our goal should be to achieve equal or even greater success in 
reducing other types of medical mistakes. This legislation lays the 
foundation to achieve this goal. I look forward to working with my 
colleagues and with interested Members of the House of Representatives 
in enacting the Patient Safety Improvement and Medical Injury Reduction 
Act.
                                 ______