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How Safe Is Our Health Care System?
What States Can Do to Improve Patient Safety and Reduce Medical Errors
Workshop Brief for State Health Officials
This workshop was designed for senior State policymakers from the executive and legislative
branches of government responsible for State health policy. The workshop was held in Boston,
Massachusetts, on March 20-22, 2000.
About the Workshop Sponsor.
Health services researchers estimate that between 44,000 and 98,000 Americans die each year as
a result of medical errors. If considered in the statistics, errors in patient care would rank number
eight among causes of death in the United States. Costs to the Nation of such preventable errors
are estimated to be between $17 and $29 billion.
Although most Americans are aware
that medical errors occur, the extent of the problem was fully realized by the general public when
the Institute of Medicine (IoM) published its December 1999 report entitled, To Err is Human:
Building a Safer Health System.
In addition to describing the prevalence and possible causes of medical errors, the IoM report
included several recommendations, some of which are directed toward States. One
recommendation calls for a nationwide mandatory reporting system that provides for the
collection of standardized information by State governments about adverse events that result in
death or serious harm. If they are to implement this recommendation, States will need
information about how such systems work in other States and how to balance the advantages of
such systems in improving accountability and stimulating quality improvement against concerns
about disclosure of information and fears that such disclosures will increase malpractice
The objectives for participants in this workshop included:
- Understanding the nature and severity of medical errors, their causes and consequences for
healthcare quality and costs.
- Gaining insight into a conceptual framework and systems approach to address issues of
- Identifying what policy and practice levers States can use to prevent medical errors and
improve patient safety.
- Learning how existing State programs that address the IoM recommendations work and how
they could be replicated in other States.
Workshop participants included representatives from State executive offices, State legislative
offices, offices of the States' attorneys general, State employee health and benefits offices, State
departments responsible for healthcare licensure and insurance, public health departments, State
Medicaid agencies, national associations representing State officials, State commissions
overseeing the quality of healthcare, independent State data and cost commissions, Federal
officials for disease control and prevention, and researchers.
Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health Care System. Washington (DC): Institute of Medicine, 2000.
AHRQ's User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of Federal, State, and local policymakers, and other health services research users, such as purchasers, administrators, and health plans.
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