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TESTIMONY BY: TOMMY G. THOMPSON, SECRETARY OF HEALTH AND HUMAN SERVICES PLACE Given to the Senate Health, Education, Labor and Pensions Subcommittee on Public Health DATE: May 24, 2001
"Medical Errors"
I also want to thank my friend Secretary O'Neill for his testimony. His role in improving patient safety in Pittsburgh is a wonderful example of what can happen when people from all sectors of society come together to solve patient safety problems. I'll be visiting Pittsburgh next week and look forward to seeing firsthand how the changes Secretary O'Neill helped implement are working.
Let me also commend you, Mr. Chairman, and the members of this committee for your commitment to solving this problem. Your work has been vital, and I thank you for it.
As you know, up to 100,000 Americans die each year as a result of medical errors, making medical mistakes the 8th leading cause of death in the US. This would be like two passenger aircraft going down every three days. Think of the publicity such airline errors would draw.
Medical errors result in approximately $29 billion in excess health care expenditures and lost productivity each year. Overwhelmingly, these problems are not the fault of individual doctors, nurses and other clinicians. Our health care workforce is comprised of the most talented and dedicated professionals in the world. Rather, these problems are substantially the result of inadequate systems of care.
The good news is that there are some very promising ways to improve health care safety. At the root of these remedies are technology and common sense.
Let me give you a few examples of how the combination of new technology and old- fashioned common sense can save lives and save money.
First, there is great potential for using the bar-coding technology so prevalent in our society today as an effective safeguard against medical mistakes. Physicians and nurses would be able to scan the bar code on a bracelet worn by a patient to monitor what medications they are on and effectively administer medicines.
Grocers use this technology to record our purchases of toothpaste and aspirin, and this simple technology could be used to track the dispensing and usage of pharmaceuticals and prevent mistakes. Simple human error would be curtailed significantly.
Bar coding would also reduce stress on overworked nurses and provide real cost savings. In fact, the health care industry has projected that broad use of bar coding across the medical supply chain could result in savings of more than $11 billion.
Bar Coding holds such great potential that I have instructed the Administration for Healthcare Research and Quality (AHRQ) to study how it might be used effectively.
A second example takes advantage of everyday computer technology. Evidence suggests that errors are significantly reduced if a physician types a prescription into a computer. Many doctors write quickly, and a typed message avoids the simple but serious problem of illegibility.
Also, clinical protocols and warnings can easily be built into computerized systems so that potential drug interactions, miscalculations of dosage and other types of errors are caught by a computer program, which will warn the doctor about possible problems. The Department of Defense and the Veterans Administration are already using this technology in their hospitals and clinics.
Another common sense idea is called "sign your site." Patients and their surgeons initial the site on the body that needs surgery with a special pen. When the patient is ready for surgery, the attending surgeon knows exactly where to operate. This is a real problem that was identified by the institutes of medicine and has also been highlighted in the media.
Then there's the "pedicap." One of the problems with intubating infants is that it is difficult to know if the baby has gotten the air tube into his or her little lungs or if the tube has gone into the esophagus.
To ensure that the baby is actually getting air, the tube can be attached with a "pedicap," a device that changes color when air is actually flowing into the infant's lungs. If it doesn't change color, the physician knows the tube has been misplaced.
These are just a few of the many remarkably simple, common sense ways we can improve medical safety for everyone. In July, we at the Department of Health and Human Services will be releasing a report that examines the evidence for various practices and technologies that could lead to improved patient safety.
That report, along with the kinds of technologies I've just shown, is important to the mission of HHS and to the health care all Americans receive. We owe it to our families, friends and neighbors to see that these effective system improvements are incorporated in our hospitals and doctors' offices.
The Institute of Medicine (IOM) report on medical errors offers recommendations that deal with what can be done to improve safety at hospitals and clinics.
However, the report also addresses what those of us who set policy and write regulations governing the health care system can do to enhance the system by which patients are safeguarded.
The President's budget for HHS includes $72 million to address issues of medical errors and patient safety. This is an increase of $15 million over FY 2001.
The request includes $53 million for AHRQ's continuing research into medical errors … $17 million for the FDA to improve adverse event reporting and response systems … and $2 million for the CDC to enhance its response to infections patients get at hospitals.
During the current fiscal year, AHRQ is investing $50 million in new research on medical errors. The FDA also has an initiative underway to improve the labeling of drugs. And we're working toward greater coordination between Federal agencies and the public and private sectors.
Several weeks ago, I announced the formation of a Patient Safety Task Force within HHS to coordinate an effort to collect patient safety data within my department and enable us to learn more about how to prevent errors.
This system is intended to help health professionals and health care organizations learn from mistakes. We need to collect as much data as possible to enhance our opportunity to learn and do better.
We have designed the system to be confidential because we believe confidentiality will increase the number of reports received, as the IOM report suggested. Giving doctors, nurses and other providers the security of knowing that the information they report cannot be used to punish them in the future can strengthen data reporting.
Also, we must not unduly burden providers with additional paperwork requirements. These dedicated people already are overwhelmed with paperwork, much of it imposed by federal programs and private health plans.
The system we design together must strike a balance between the need to obtain information - and the reality that doctors and nurses can spend more time with their patients when they don't have to submit form after form to a government agency.
At the same time, we want to increase the usefulness of the information to the medical community and the public. Our system, once fully implemented, will make it easier for front-line doctors, nurses, managers and others to help us capture the data we all need to improve patient safety.
Finally, our patient safety data collection system will facilitate quick analyses, as well as longer-term research.
Mr. Chairman, let me close by emphasizing that President Bush and we at HHS wholeheartedly share your commitment to improve patient safety. We understand the need and our budget commitments reflect that understanding.
I look forward to working with you and the committee to that end. Thank you, and i'm glad to answer your questions.