[Weekly Compilation of Presidential Documents Volume 36, Number 8 (Monday, February 28, 2000)]
[Pages 351-353]
[Online from the Government Publishing Office, www.gpo.gov]

<R04>
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.

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    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?
    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.

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    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 mix-ups 
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 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.