{ "id": "RL31983", "type": "CRS Report", "typeId": "REPORTS", "number": "RL31983", "active": false, "source": "EveryCRSReport.com, University of North Texas Libraries Government Documents Department", "versions": [ { "source": "EveryCRSReport.com", "id": 306644, "date": "2005-03-24", "retrieved": "2016-04-07T19:48:59.403029", "title": "Health Care Quality: Improving Patient Safety by Promoting Medical Errors Reporting", "summary": "In the 108th Congress, the House and Senate passed competing versions of the Patient Safety\nand\nQuality Improvement Act ( H.R. 663 , S. 720 ), but the differences between\nthe two measures were never resolved. On March 9, 2005, the Senate Committee on Health,\nEducation, Labor, and Pensions unanimously approved S. 544 , which is identical to\n S. 720 . The legislation would establish legal protections for data and reports\non medical errors in an effort to encourage voluntary reporting of such information. The patient\nsafety bills are in response to the 1999 Institute of Medicine (IOM) report To Err Is Human ,\nwhich\nconcluded that preventable medical errors cause as many as 98,000 deaths a year. The IOM found\nthat medical errors are primarily the result of faulty systems, processes, and conditions that lead\npeople to make mistakes. It recommended establishing a national mandatory reporting system to\nhold hospitals accountable for serious medical errors, as well as developing voluntary, confidential\nsystems for reporting errors that result in little or no harm. Analysis of such voluntarily reported data\ncould be used to identify vulnerabilities in health care systems.\n \n Twenty-two states mandate medical error reporting by hospitals. However, providers are\nreluctant to report adverse events in part because they fear that the information will be used in\nmalpractice litigation. States have sought to allay those concerns by passing laws to protect reported\ndata from legal discovery and by de-identifying data and receiving reports anonymously. Such\nmeasures risk limiting the usefulness of the data for research and quality management.\n \n There are several national voluntary reporting systems for medical errors, including the Patient\nSafety Information System within the Department of Veterans Affairs. Analysis of these and other\nvoluntary reporting systems -- notably the Aviation Safety Reporting System -- has identified several\ndesign features associated with effective programs. For example, the reporting process should be\nuser-friendly and the information kept confidential and protected from legal discovery. Also, reports\nshould be promptly evaluated by experts who are trained to recognize underlying systems causes,\nand reporters should receive timely feedback with recommendations for systems-based\nimprovements.\n \n To encourage voluntary reporting, H.R. 663 would have protected reported\ninformation from legal discovery in civil and administrative proceeding, and from a Freedom of\nInformation Act request. The bill required the Agency for Healthcare Research and Quality (AHRQ)\nto certify patient safety organizations to collect and analyze the information reported by providers. \nSuch organizations would develop and disseminate recommendations for systems-based solutions\nto improve patient safety and health care quality. H.R. 663 also would have required\nAHRQ to establish a national database to receive and analyze de-identified information submitted\nby patient safety organizations. S. 544 would protect information from use in criminal\nas well as civil and administrative proceedings, unless a judge determined that it contained evidence\nof an intentional act to directly harm the patient. This report will be updated as legislative events\nin the 109th Congress warrant.", "type": "CRS Report", "typeId": "REPORTS", "active": false, "formats": [ { "format": "HTML", "encoding": "utf-8", "url": "http://www.crs.gov/Reports/RL31983", "sha1": "22742dfbdaef01f1f145bf0b5243c1e86fbfeda7", "filename": "files/20050324_RL31983_22742dfbdaef01f1f145bf0b5243c1e86fbfeda7.html", "images": null }, { "format": "PDF", "encoding": null, "url": "http://www.crs.gov/Reports/pdf/RL31983", "sha1": "3caeb14df0822f127aaade1730bbd5f0261d8fdd", "filename": "files/20050324_RL31983_3caeb14df0822f127aaade1730bbd5f0261d8fdd.pdf", "images": null } ], "topics": [] }, { "source": "University of North Texas Libraries Government Documents Department", "sourceLink": "https://digital.library.unt.edu/ark:/67531/metadc821116/", "id": "RL31983_2003Nov26", "date": "2003-11-26", "retrieved": "2016-03-19T13:57:26", "title": "Patient Safety: Legislation to Promote Voluntary Reporting of Medical Errors", "summary": "This report provides an overview and some analysis of the patient safety legislation that is being considered by the 108th Congress. It begins with background information on the nature and causes of medical errors, followed by a brief comparison of the differences between mandatory and voluntary reporting systems. The report then discusses some of the legal and policy issues facing state mandatory reporting systems and major national voluntary reporting systems, and identifies design features of effective reporting programs. It concludes with a discussion and side-by-side comparison of H.R. 663 and S. 720.", "type": "CRS Report", "typeId": "REPORT", "active": false, "formats": [ { "format": "PDF", "filename": "files/20031126_RL31983_981234fddaa7903a0cebbd93c046ef72c7e673c9.pdf" }, { "format": "HTML", "filename": "files/20031126_RL31983_981234fddaa7903a0cebbd93c046ef72c7e673c9.html" } ], "topics": [ { "source": "LIV", "id": "Medicine", "name": "Medicine" }, { "source": "LIV", "id": "Medical ethics", "name": "Medical ethics" }, { "source": "LIV", "id": "Patients' rights", "name": "Patients' rights" } ] } ], "topics": [ "Health Policy" ] }