ABC News, 6:45 PM,
Tuesday, November 30, 1999
Cost more than $28
billion per year.
Kill 44,000 to
98,000 patients per year
How many due to
affirmative action? NOTHING.
How many are men?
November 30, 1999
Clinton Urges War on Medical Errors
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Filed at 10:28 a.m. EDT
By The Associated Press
WASHINGTON (AP) -- President Clinton called today for health care
providers to work with government and other entities to curb medical
errors that a new report says kill thousands of hospital patients each year.
Clinton said he welcomed the report issued Monday by the Institute of
Medicine, which quoted studies estimating that at least 44,000 and
perhaps as many as 98,000 hospitalized Americans die every year from
During an Oval Office announcement on parental leave, Clinton told
reporters he suggested some sort of partnership to a leading managed
care provider on Monday, ``and they agreed with that, that we've all got
to get together'' to resolve the problem.
``No one has an interest in seeing these kinds of mistakes made. And we
know that otherwise competent people are making a lot of these
mistakes,'' Clinton said. ``We've got to work through how we can use
technology, and how we can maybe even slow some of the actions, to
make sure that mistakes like this aren't made.''
``To err is human'' is the report's title, but it stresses that ways exist to
prevent many mistakes by anticipating health workers' weaknesses and
The report recommends major changes to the nation's health care system
to set as a minimum goal a 50 percent reduction in medical mistakes
within five years.
``Errors can be prevented by designing systems that make it hard for
people to do the wrong thing and easy for people to do the right thing,''
said William Richardson, president of the W.K. Kellogg Foundation,
who co-authored the report.
There are constant places for doctors, nurses, pharmacists and other
health workers to trip.
Doctors' notoriously poor handwriting too often leaves pharmacists
squinting to decipher a dose -- was it 10 milligrams or 10 micrograms? --
or even the name of the prescribed drug.
Too many drug names sound confusingly alike. Consider the painkiller
Celebrex and the anti-seizure drug Cerebyx; or Narcan, which treats
morphine overdoses, and Norcuron, which can paralyze breathing
Medical knowledge grows so rapidly that it is difficult to stay abreast of
the latest treatment or newly discovered danger. Technology poses
hazards when device models change from year to year, leaving doctors
fumbling for the right switch.
And most health professionals do not have their competence regularly
retested after receiving their license to practice, the report said.
In fact, health care is a decade behind other high-risk industries in
improving safety, the report said. It pointed to the transportation industry
as a model: Just as engineers design cars so they cannot start in reverse,
and airlines limit pilots' flying time to keep them rested, so can health care
Some fixes already are under way: Some hospitals have computerized
prescriptions. The Food and Drug Administration is hunting ways to
catch sound-alike drugs. Anesthesiologists persuaded many
manufacturers to standardize equipment and thus decreased
technology-caused errors. Many doctors now literally mark the spot of
surgical incisions before patients are put to sleep, so everyone agrees on
what will be cut.
But the Institute of Medicine said reducing medical mistakes requires a
bigger commitment. It recommended:
--Congress should establish a federal Center for Patient Safety. It would
require $35 million to start and should eventually spend $100 million a
year in safety research. Still, that represents just a fraction of an estimated
$8.8 billion spent yearly as a result of medical mistakes, the report
--The government should require that hospitals, and eventually other
health organizations, report all serious mistakes to state agencies so
experts can detect patterns of problems and take action. About 20 states
now require error reporting, but how much and what penalties they
impose varies widely.
--State licensing boards and medical accreditors should periodically
re-examine health practitioners for competence, stressing safety
practices. Standardized medical equipment and treatment guidelines can
help doctors keep up.
--Change the ``culture of secrecy'' that surrounds medical mistakes,
encouraging doctors to discuss errors as well as near-misses so problems
The Institute of Medicine is part of the National Academy of Sciences, a
private organization chartered by Congress to advise the government on
scientific matters. Congress just passed legislation ordering the Agency
for Health Care Policy and Research to hunt strategies to reduce medical
mistakes. The bill will even change the name to the Agency for
Healthcare Research and Quality to reflect the emphasis. President
Clinton is expected to sign the bill soon.
``Any error that causes harm to a patient is one error too many,'' said Dr.
Nancy Dickey, past president of the American Medical Association,
which already has started a National Patient Safety Foundation to
address some of the problems.
But she cautioned that some changes will be difficult because doctors are
liable for any mistake. ``We may know to talk about a culture of safety,
but we still live in an environment of blame,'' she said.
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