Medical mistakes study highlights need for systemwide improvements.

A recent National Academy of Sciences (NAS) study revealing what its authors call the "stunningly high rates" of medical errors in hospitals has grabbed the attention of the president, Congress, doctors, and trial lawyers--all of whom have pledged to work together to protect the public from dangerous and avoidable mistakes.

The study, To Err Is Human: Building a Safer Health System, found that between 44,000 and 98,000 hospital patients die each year as a result of errors that can be attributed primarily to a flawed health care system with built-in opportunities for blunders rather than to individual doctors and other medical professionals.

Among the deadly mistakes that occur are stocking patient-care units in hospitals with certain full-strength drugs even though they are toxic unless diluted; illegibly handwriting orders that may result in giving patients drugs to which they are allergic; and incorrectly operating or programming increasingly complex medical devices.

"These stunningly high rates of medical errors--resulting in deaths, permanent disability, and unnecessary suffering--are simply unacceptable in a medical system that promises first to `do no harm,'" said William Richardson, chair of the NAS Institute of Medicine committee that wrote the report. "Our recommendations are intended to encourage the health care system to take the actions necessary to improve safety. We must have a health care system that makes it easy to do things right and hard to do them wrong."

The committee's recommendations to curb avoidable errors include

* creating a federal agency--similar to the Federal Aviation Administration and the Occupational Safety and Health Administration--to establish and track progress toward national medical safety goals and to act as a clearinghouse for objective information on patient safety;

* creating national reporting systems --some mandatory and some voluntary--to chart medical errors so practitioners and the public can learn about and from mistakes that have occurred;

* having state licensing boards and medical accreditors periodically reexamine health practitioners to ensure professional competence and adherence to safety practices; and

* building a"culture of safety" in health care settings by designing systems geared toward preventing, detecting, and minimizing hazards and the likelihood of error.

ATLA President Richard Middleton Jr. applauded the committee's recommendations for building a safer health care system and said the association will work with Congress, the White House, and the medical profession to enhance the quality of health care for Americans. But he remained a staunch defender of the public's right to hold hospitals and individual doctors responsible for these mistakes.

"While we will oppose any measure which would shield misconduct or restrict remedies when medical errors destroy lives, we are committed to helping eliminate errors that make it necessary for patients and their loved ones to seek legal relief," Middleton said.

Sidney Wolfe, director of Public Citizen's Health Research Group in Washington, D.C., said he believes the committee's study is on target about the systemic problems that result in medical errors within hospitals. "But I'm just as concerned about what's happening outside the hospital," he said.

"I am one who believes you have to have a simultaneous approach, looking at the problems within the system and at the negligence that occurs in and out of the hospital by individual doctors. The system for looking at what individual doctors do outside the hospital doesn't really exist yet."

The NAS committee noted that while its study focused only on hospitals, it would recommend mandating reporting systems for other places that provide health care, such as clinics and doctors' offices.

Shortly after the study was released in late November, President Clinton appointed a task force to report by mid-February on ways to prevent medical mistakes and improve patient safety. In an executive order, he mandated that the 300 private health plans that sell insurance to federal employees must institute patient safety initiatives. The president also directed federal agencies that administer health plans, such as Medicaid and Medicare, to evaluate and begin using the latest techniques to reduce medical errors.

Sen. Edward Kennedy (D-Mass.) has promised to introduce legislation based on many of the committee's recommendations, including a law requiring hospitals to notify state governments of all mistakes that cause serious injuries or deaths.

For a copy of the $45 report, contact Academy Press Customer Service at [phone] or read the report online at http:// www.nap.edu/books/0309068371/html/.