National Summit on Medical Errors and Patient Safety Research
Summary: Opening Remarks
John Eisenberg, M.D., M.B.A., Director, Agency for Healthcare Research and Quality
On September 11, 2000, as part of the Government's response
to the Institute of Medicine's landmark November 1999 report,
To
Err is Human: Building a Safer Health System, the Federal
Quality Interagency Coordination (QuIC) Task Force sponsored a
national summit to help set a research agenda on medical errors
and patient safety. A summary of part of that Summit follows.
Other Summit information includes: Written Statements of panel testimony, Additional Statements, and Streaming Video.
Opening Remarks: John Eisenberg, M.D., M.B.A.
The purpose of this National Summit on Medical Errors and Patient Safety Research was to set
priorities for a national research agenda to address the issue of medical errors and patient
safety. This issue has been recognized as one with a far-reaching impact, affecting consumers
and health care professionals alike, both in the U.S. and abroad. In that sense, it is a significant
public health problem and accordingly, it must be treated as one.
Dr. Eisenberg likened the
problem of medical errors to an epidemic, and noted that we are currently in the first stage of
understanding the epidemic. Research is necessary to understand the magnitude of the
problem, its causes, and its burden on people, which will provide information crucial to
developing a cure. Similar to the wars that have been waged on diseases such as cancer and
heart disease, the war on medical errors will start with research, which must later be translated
into high-quality and safe medical care for all.
The Institute of Medicine (IOM) report, released in November of 1999, estimated that 44,000-
94,000 Americans die each year as a result of medical errors, and the annual cost attributable to
medical errors is $29 billion in additional health care burdens. If money can be invested in
appropriate research, the payoff will be twofold: saving money and, most importantly, saving
lives.
Soon after the release of the IOM report, the Quality Interagency Coordination Task Force
(QuIC) was charged by the President to develop a Federal response to the IOM report by
coordinating all Federal agencies with an interest in quality health care to explore Federal
actions to address the problem. In its report to the President, Doing What Counts for Patient
Safety: Federal Actions to Reduce Medical Errors and their Impact, the QuIC, among other
recommendations, proposed to convene several national summits and expert meetings to
review research needs related to patient safety and to develop a responsive national research
agenda.
The National Summit brought together users of research, funders of research, and researchers
themselves in a forum where needs were examined and actions were recommended. The
funders at the Summit represented broad-based coalitions of organizations interested in
investing in research, including:
- Self-funded and private health care systems (Department of
Defense, Department of Veterans Affairs, Premier Health Care Systems, Commonwealth Fund, Kaiser Family Foundation, Robert Wood Johnson Foundation, California Health Foundation, Grantmakers in Health, National Patient Safety Foundation, Jewish Healthcare Foundation).
- Private and public purchasers (Aetna U.S. Healthcare, Health Care Financing Administration).
- Public health agencies (Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention).
- International representation from New Zealand, Britain, and
Australia.
The users at the Summit represented five areas: consumers and purchasers; broad-
based system approaches; particular system issues; reporting issues and learning approaches;
and state coalitions and public policy advocates.
Dr. Eisenberg recognized that reducing medical errors and enhancing patient safety will require
a long-term investment and international commitment. He also emphasized that improving
patient safety is not just an issue that reflects the Federal government, private sector, or the
US alone. It is an international problem that will require a cooperative, unified, and
diversified approach to ensure that every patient receives the highest quality medical care
possible.
Current as of September 2000
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