    [Public Papers of the Presidents of the United States: WILLIAM J. CLINTON (2000, Book I)]
    [February 22, 2000]
    [Pages 285-287]
    [From the U.S. Government Publishing Office www.gpo.gov]

    Remarks on Efforts To Improve Patient Safety
    February 22, 2000

        Thank you very much. Let me begin by thanking Barbara
    Blakeney for her words and her work on
    the frontlines of health care, and for the true visionary leadership
    that the nurses of our country have given efforts for health care
    reform, certainly for all the days that I have been privileged to be
    here as President, and long before.
        I want to thank Secretary Shalala and
    Secretary Herman for the work that they
    have done on the whole issue of quality health care, on medical errors,
    and their pioneering work for the Patients' Bill of Rights.
        I thank Senator Jeffords, Senator
    Specter, and Senator Harkin for being here. They had an important hearing today, and
    I can tell you that--I was talking to them for a few moments outside--
    they are passionately interested in and very well-informed about this
    issue. And as we all know, when we have a bipartisan commitment in the
    Congress to solving a problem in America, it normally gets solved. And I
    thank you all very much for your dedication.
        I want to thank all the people who are here from the National
    Government. John of AHRQ--I like that.
    That's pretty good. [Laughter] Tom Garthwaite, Sue Bailey, Paul
    London, all the people here from all the
    other agencies who have worked so hard on this. Thank you very, very
    much. Thank you, Ken Kizer. I thank the leaders
    representing consumers, health care plans and providers, business,
    labor, and quality experts who are here. And of course, I want to thank
    the National Academy of Sciences' Institutes of Medicine for its
    landmark report.
        As Secretary Shalala said, the IOM study focused new light on what
    has been a high priority of ours, which is ensuring that all Americans
    get the highest quality health care in the world. Secretary Herman
    pointed out that this is about more than saving lives--the dollar cost
    of--it is about more than money, and it's even about more than saving
    lives, because it's about the toll in lost trust in the health care
    system. We heard a lot about it when the IOM study came out.
        But we know that if we do the right things, we can dramatically
    reduce the times when the wrong drug is dispensed, a blood transfusion
    is mismatched, or a surgery goes awry. As I have said many times, I will
    say again, I'm not here to find fault. I'm here to find answers.
        We do have the best health care system in the world, the finest
    health professionals in the world. New drugs, new procedures, new
    technologies have allowed us to live longer and better lives. Later this
    year, when researchers finish the mapping of the human genome, it will
    lead to even greater advances in our ability to detect, treat, and
    prevent so many, many diseases.
        But the growing advances have been accompanied by growing complexity
    in our health care delivery system. I might say it's complicated by the
    choices we have made about how we finance it and operate it. So the time
    has plainly come, as a result of the IOM study, to just take a step back
    and ask ourselves: How can we redesign the system to reduce error? Have
    we given all of our caregivers adequate training? Do they adequately
    coordinate with and communicate with one another? Do all settings have
    the right kinds of teams and systems in place to minimize mistakes?

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        These are the kinds of questions that were asked and answered in our
    landmark efforts as Americans to improve aviation safety and workplace
    safety. And if these questions are properly asked and answered in the
    context of the health care system, they will dramatically reduce errors
    there as well.
        Last December I directed our own Health Care Quality Task Force to
    analyze the IOM study, to report back with recommendations about how we
    can follow the suggestions they made to protect patients and promote
    safety. This morning I received the task force report, and I am proud to
    accept all its recommendations.
        Our goal is to reduce preventable medical errors by 50 percent
    within 5 years. Today I announce our national action plan to reach that
    goal.
        First, we agree with the need to establish a focal point within the
    Federal Government to target this challenge. So today I propose the
    creation of a new center for quality improvement in patient safety. My
    budget includes $20 million to support the center, which will invest in
    research, develop national goals, issue an annual report on the state of
    patient safety, and translate findings into better practices and
    policies.
        Second, we will ensure that each and every one of the 6,000
    hospitals participating in Medicare has patient safety programs in place
    to prevent medical errors, including medication mistakes. These new
    systems save lives and over time, of course, also save money. I commend
    hospitals for the steps they have already taken, and we'll work with
    them and other health care experts to develop this regulation in the
    coming months.
        Third, as we seek to make sure that the right systems are in place,
    we need to make sure they are working. Today I am releasing our plan for
    a nationwide, State-based system of reporting medical errors, to be
    phased in over time. This will include mandatory reporting of
    preventable medical errors that cause death or serious injury, and
    voluntary reporting of other medical mistakes and so-called near misses
    or close calls.
        Reporting is vital to holding health care systems accountable for
    delivering quality care and educating the public about the safety of
    their health care system. It is critical to uncovering weaknesses,
    targeting widespread problems, analyzing what works and what doesn't,
    and sharing it with others.
        Twenty-one States already have mandatory error reporting systems. We
    want to make sure they have the tools to do it right, and that every
    other State will follow suit. That's why we'll be working with the
    National Quality Forum, a private-public group of health care experts,
    to develop a set of patient safety measurements that would lay the
    foundation for a uniform system of reporting errors.
        We also want to replace what some call a culture of silence with a
    culture of safety, an environment that encourages others to talk about
    errors, what caused them, and how to stop them in the first place. So
    we'll support legislation that protects provider and patient
    confidentiality, but that does not undermine individual rights to
    remedies when they have, in fact, been harmed. People should have access
    to information about a preventable medical error that causes serious
    injury or death of a family member, and providers should have
    protections to encourage reporting and prevent mistakes from happening
    again.
        And when it comes to reporting, we want the Federal Government to
    continue to lead by example. The Department of Veterans Affairs already
    has a mandatory reporting system for death and serious injuries.
    Beginning this spring, all 500 Department of Defense hospitals and
    clinics will do the same. And the VA will add a voluntary reporting
    system in its hospitals nationwide.
        Finally, I'm announcing a number of new steps we will take that
    specifically target medication errors. Each year, medication mixups
    claim thousands of lives. Sometimes mistakes occur because many
    different drugs sound or look the same, sometimes because people are
    taking multiple medications and going to multiple doctors.
        I'm calling on the Food and Drug Administration to develop new
    standards to help prevent medical errors caused by drugs that sound
    similar or packaging that looks similar. In addition, we'll develop new
    label standards that highlight common drug interactions and dosage
    errors. The VA will also put in place computerized systems to prevent
    medication mistakes; no more handwritten prescriptions that no one can
    read.
        Hospitals that have already taken these steps have eliminated--
    listen to this--two out of three medication errors. This is very
    significant. We tend to think all of our problems are the result

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    of some complex, high-tech glitch. We just want to make sure people can
    read the prescriptions. Two out of three of these errors can be
    eliminated.
        Taken together, these actions represent the most significant effort
    our Nation has ever made to reduce medical errors. It's a balanced,
    commonsense approach based on prevention, not punishment; on
    problemsolving, not blame-placing.
        If we can do this and pass a strong, enforceable Patients' Bill of
    Rights, we will have gone a long way toward ensuring quality health care
    for all Americans in the 21st century. Just think about it. We can cut
    preventable medical errors in half in 5 years, reduce concerns about
    lawsuits and about medical mistakes, avoid needless injuries and deaths,
    save lives, and make the world's best health care system much better for
    all Americans.
        This is a worthy endeavor. It is one that, as you see, will be
    bipartisan, and one that I am committed to seeing through. Thank you all
    for being here, and let's get about the business of doing this.
        Thank you.

    Note: The President spoke at 12:53 p.m. in Presidential Hall in the
    Dwight D. Eisenhower Executive Office Building. In his remarks, he
    referred to Barbara A. Blakeney, first vice president, American Nurses
    Association, who introduced the President; John M. Eisenberg,
    Administrator, Agency for Healthcare Research and Quality; and Paul A.
    London, Senior Policy Adviser to the Secretary, Department of Commerce.