[Congressional Record (Bound Edition), Volume 151 (2005), Part 12]
[Senate]
[Pages 16891-16892]
[From the U.S. Government Publishing Office, www.gpo.gov]




           PATIENT SAFETY AND QUALITY IMPROVEMENT ACT OF 2005

  Mr. WARNER. Mr. President, I ask unanimous consent that the HELP 
Committee be discharged from further consideration of S. 544 and the 
Senate proceed to its immediate consideration.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The clerk will report the bill by title.
  The legislative clerk read as follows:

       A bill (S. 544) to amend title IX of Public Health Service 
     Act to provide for the improvement of patient safety and to 
     reduce the incidence of events that adversely affect patient 
     safety.


[[Page 16892]]


  There being no objection, the Senate proceeded to consider the bill.
  Mr. KENNEDY. Mr. President, I commend Senator Enzi, Senator Gregg, 
Senator Jeffords, Senator Frist, and all of the other members of our 
Health Committee who have done so much to achieve this bipartisan 
consensus on the complex issue of preventing medical errors and 
improving patient safety. I also commend our colleagues in the House of 
Representatives, especially Chairman Barton of the Committee on Energy 
and Commerce, and the ranking member of that committee, Representative 
Dingell, for their willingness to work with us to resolve the 
differences between the House and Senate bills on this important issue.
  For even one American to die from an avoidable medical error is a 
tragedy. When thousands die every year from such errors, it is a 
national tragedy, and it is also a national disgrace, and an urgent 
call to action.
  Five years ago, the Institute of Medicine reported that medical 
errors cause 98,000 deaths every year. That is an average of 268 deaths 
a day, every day. If errors in aviation killed 200 passengers a day in 
plane crashes, we would do more than simply encourage voluntary 
reporting. If errors at factories caused the deaths of 200 workers a 
day, we would demand more than corporate reports. We would require real 
changes.
  Unfortunately, the culture of medicine has an expectation of 
infallibility in health professionals, and this unrealistic assumption 
has been reinforced by generations of medical training and medical 
practice.
  When confronted with a mistake in health care, doctors and patients 
and citizens often ask, ``How can there be errors without negligence?'' 
Obviously, the fear of legal liability or embarrassment among peers and 
in the press leads to strong pressure to cover up mistakes.
  In many cases, however, the inadequate design and implementation of 
health systems are responsible for the problem, including excessive 
work schedules and unreasonable time pressures.
  We can do better. We can encourage the development of a safer health 
care system. We can learn important lessons from other dangerous 
fields, such as the aviation industry and the military, which are 
skillful in designing ways to provide maximum feasible safety.
  The Institute of Medicine has called for strong action, and our 
proposal is responding to that call. The Institute's series of reports 
on health care quality contain numerous recommendations for improving 
patient safety, and if we work together, we can make more of them a 
reality.
  The Institute recommended that health care professionals should be 
encouraged to report medical errors, without fearing that their reports 
will be used against them. Our legislation implements this sensible 
recommendation by establishing patient safety organizations to analyze 
medical errors and recommend ways to avoid them in the future. The 
legislation also creates a legal privilege for information reported to 
the safety organizations, but still guaranteeing that original records, 
such as patients' charts will remain accessible to patients.
  Drawing the boundaries of this privilege requires a careful balance, 
and I believe the legislation has found that balance. The bill is 
intended to make medical professionals feel secure in reporting errors 
without fear of punishment, and it is right to do so. But the bill 
tries to do so carefully, so that it does not accidentally shield 
persons who have negligently or intentionally caused harm to patients. 
The legislation also upholds existing state laws on reporting patient 
safety information.
  The legislation can be the beginning of more effective action on 
patient safety, but other reforms are also necessary. The Federal 
Government should have a leading role in improving safety and improving 
the quality of care for patients. The title of one of IOM's most 
important reports, Leadership by Example, highlights the central role 
that the Federal Government should have on this issue.
  Other actions are also necessary. Hospital systems that have improved 
health care quality have done so by making far-reaching reforms in 
which improving health care quality is a key part of the practice of 
medicine. To turn best practices into everyday practices, hospitals 
have created clinical guidelines and assessments of outcomes to help 
see that every patient receives the best possible care.
  The Senate is acting to approve needed legislation on the use of 
information technology in health care, such as in electronic medical 
records, decision support software, and computer reminders for needed 
screening tests. These and other features of health IT systems can 
improve overall health care. In a culture where doctors can learn from 
mistakes and near misses, these IT systems can dramatically improve 
health care for all Americans.
  I commend my colleagues on both sides of the aisle and both sides of 
the Capitol, who came together to bring this major legislation to a 
vote, so that every patient in America will receive effective, high 
quality health care.


                           Amendment No. 1411

  (Purpose: In the nature of a substitute)
  Mr. WARNER. I ask unanimous consent that the amendment at the desk be 
agreed to, the bill, as amended, be read the third time and passed, the 
motion to reconsider be laid upon the table and that any statements 
relating to the measure be printed in the Record.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  The amendment (No. 1411) was agreed to.
  (The amendment is printed in today's Record under ``Text of 
Amendments.'')
  The bill (S. 544), as amended, was read the third time and passed.

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