Newsletter Winter 2000
Managed Care Organizations (MCO)

Fatal mistakes and misuse of medical technology are now the eighth major cause of death in the United States. The IOM recognizes the estimates are low for two important reasons. First, the data was extracted from medical records only, recognizing that many injuries and most errors are either not recorded (by intent or inadvertent omission) in the medical record. Second, outpatient injuries are excluded, where without hospital safeguards, regulations and peer review, errors may be much higher (1).

The IOM report goes on to recommend that $30 million to be spent creating a new National Patient Safety Center. This center would set national safety goals, track progress in meeting them, and invest in research to learn about prevention. It would also serve as a clearinghouse on the latest information on patient safety.

The fundamental recommendation on reporting medical errors is very controversial. Two types of medical reporting systems are identified: voluntary reporting of errors that result in minimal or no harm; and mandatory reporting of errors resulting in death or serious permanent injury. Many fear that reporting egregious events will dramatically increase malpractice liability. The IOM believes that a no-fault compensation and enterprise liability may lend itself to a more conducive legal environment.

In the New England Journal of Medicine critics of the IOM state that while the report gives the impression that doctors and hospitals are doing very little about the problems of safety, the opposite is true. Safety has improved, deaths from substandard care have decreased and mortality from both common and sophisticated procedures has declined, largely due to advances in technology. The critics contend that systematic approaches to prevention of medical errors will be expensive to build, upgrade and maintain, with costs ultimately be passed onto the insurers and health plans (2).

New strategies to reduce Medical errors
Dr, Simmons, President of the National Coalition on Health Care, states that the three major problems affecting health care are intertwined: rising costs, decreasing coverage and poor quality. He advocates changing the culture of medicine to emphasize best practices and “evidenced-based” care to reduce medical errors and improve quality of patient care. He suggests integrating quality-related information and payment policies into benefit contracts (3).

Computerized order entry systems, bar-coded medications and hand held wireless devices are just a few of the ways in which technological advances are playing a positive role in the reduction of medical errors. In 1993, Brigham & Women's Hospital began an inpatient computerized physician order-entry system. It has been credited with saving between $5 to 10 million dollars and reducing medication errors by 55%. The VA reported a 70% reduction in medication errors over a five-year period using bar-coded medicines and wireless computer technology and a reduction of patient readmissions due to drug interactions (4).

Challenges
The notion of how to improve health care without adding burdensome costs and bureaucratic paper work will be a major challenge. Dr. Leape of the Harvard School of Public Health, coauthor of the IOM study believes that medical errors could be reduced by 50% if more funding for patient safety research was available (5). The IOM's recommended New Patient Safety Center was slated to cost $30 million however the 2001 fiscal budget proposed by Clinton was only $20 million.

The mandatory reporting remains a major obstacle. The committee believes the public has the right to know about errors, but recommends federal legislation to protect the confidentiality of specified information, such as errors that result in no serious consequence. This would be collected and analyzed specifically so that problems can be corrected before harm occurs. Patient safety advocates believe this will force a change in the finger pointing of serious medical errors. Health care providers believe it will instigate massive lawsuits.

Technology that is unable to communicate with existing systems also will slow the process. For example, computer-ordering systems that don't interface with pharmacy systems require data to be reentered. Recent studies have shown that one-third of computerized drug entry systems surveyed allowed health providers to override errors such as prescribing inappropriate medicine for a particular condition.

Current legislation
Within the last year Congressional hearings have begun and three bills were introduced in the House and Senate to deal specifically with medical errors. The Senate bills call for mandatory reporting while the House bill calls for voluntary reporting. S.2038 would amend the Public Health Service Act to reduce accidental injury and death from medical mistakes. S.2378 amends the Social security Act to improve the safety of Medicare and Medicaid programs. H.R.3672 will provide for voluntary reporting by health professionals of medication error information to assist public and nonprofit agencies in developing and disseminating information to prevent medication errors. Currently about one-third of the states have their own mandatory reporting requirements.

Future trends
Health plans and consumers are beginning to demand better medical treatment.

The Leapfrog Group, comprising 70 businesses and organizations drafted proposals to offer hospitals incentives to improve quality and reduce preventable deaths. Leapfrog wants to prove that market forces can work to improve quality of health care. For example, recommending employees needing an operation to facilities that perform the surgery frequently, stating safety is greater at such hospitals.

Monitoring activities are also increasing. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the National Committee for Quality Assurance are aligning on patient safety standards. These agencies are advocating for safety programs that focus on improvement, not blame, in order to maintain accreditation. The new requirements also stipulate those patients and their families be informed about results of care, including unfavorable outcomes.

Recently federal health officials announced plans to reverse a long-standing policy to allow Medicare beneficiaries to obtain information about physicians that may have made mistakes in caring for patients. This would allow peer review organizations (PROs) that investigate patient complaints to disclose their findings, even if a physician objects.

1. Kohn LT, Corrigan JM, Donalson Ms, et al.; “To Err is Human: Building a Safer Health System”; Washington, DC National Academy Press, 2000

2. Brennan, TA; “The Institute of Medicine Report on Medical Errors—Could it do Harm?”; New England Journal of Medicine 2000 Apr 13; 342 (15): 1123-5.

3. Simmons, HE; “Best Practices: New Strategies to Reduce Medical Errors”; The Mayflower Hotel, Washington, DC February 22, 2000

4. Tokarski, C; “Medical Error- Prevention Strategies Face Barriers to Acceptance”; Medscape Money and Medicine 2000 May 30

5. Tokarski, C; “Reporting Requirements Cloud Consensus on Curbing Medical Errors”; Medscape Money and Medicine 2000 May 8

6. Kern, KA; “Medical Malpractice Involving Colon and Rectal Disease”; Diseases of Colon and Rectum 1993 June 36; (6): 531-9

7. Kern, KA ; “Causes of Breast Cancer Malpractice Litigation”; Archives of Surgery 1992 May; 127 (5): 542-6

8. Maguire, P “Guidelines From Malpractice Insurers?”; ACP-ASIM Observer 1998 November

9. Kostreski, F ;”Pediatricians Remain at Low Risk for Malpractice;” Pediatric News 1999; 33; (4): 7

10. Mangurten, NH, Angst DB, See, C.; “Professional Liability in a Neonatal Intensive Care Unit”; Journal of Perinatology; 2000 June 20; (4): 244-8

11. Karcz, A., Korn, R, Burke, MC; “Malpractice Claims Against Emergency Physicians in Massachusetts: 1975-1993”; American Journal of Emergency Medicine ;1996 July 14; (4): 341-5

12.Burton, E, Troxclair, D, Newman, W; “Autopsy Diagnoses of Malignant Neoplasms”; JAMA 1998 280; (14): 1245-8

13.Roosen, J, Frans, E; “Comparison of Pre-mortem Clinical Diagnosis in Critically Ill Patients and Aubsequent Autopsy Findings”; Mayo Clinic Proceedings 2000;75: 562-7