Joint Commission President Testifies Before Senate on Critical Strategies for Reducing Medical Errors

OAKBROOK TERRACE, Ill. -- The most powerful

incentive for reducing medical errors is to align payments for service

with the successful provision of safe, high quality care, the president of

the nation's leading advocate for health care quality and safety told a

Senate Committee today.

Testifying before the Senate Committee on Governmental Affairs,

Joint Commission President Dennis S. O'Leary, MD, outlined six crucial

strategies for the creation of a true culture of safety within healthcare


"The Joint Commission, like others, is deeply concerned that the

number of serious medical errors remains unacceptably high, despite the

focus of significant national attention on patient safety in recent

years," says O'Leary.

To overcome the barriers preventing health care organizations from

truly embracing patient safety, O'Leary emphasized that Congress, health

care providers and purchasers need to work together to:

Create a blame-free, protected environment that encourages the systematic

surfacing and reporting of serious adverse events.

Reinforce the "systems approach" to preventing medical errors, whereby

health care organizations assess the weak points in their systems of care

and re-design care processes by putting safeguards into place to keep

mistakes from reaching the patient.

Reform the professional educational system to produce healthcare

professionals who are proficient in executing a "systems approach" to

patient safety and are trained in team approaches to patient care.

Joint Commission president testifies before Senate

Invest in the information infrastructure of health care organizations in

order to make critical patient information available on a timely basis and

thereby support the safe and appropriate delivery of medical care to


Establish performance incentives for achieving safety objectives through

federal adoption of the Joint Commission's National Patient Safety Goals,

and align reimbursement for healthcare services with the provision of

safe, high-quality care.

Enact patient safety legislation that that would encourage the voluntary

reporting of healthcare errors and their causes by affording

confidentiality protections for such reports.

"Healthcare professionals, who work under continuous high stress,

will make errors," says O'Leary. "The goal is to prevent those errors

from reaching or affecting the patient."

The Joint Commission maintains one of the nation's most

comprehensive databases of serious adverse events and their underlying

causes. Information from this database is regularly shared with accredited

organizations to help them take appropriate preventive steps. It is also

used to establish the National Patient Safety Goals. It is believed that

the sharing of this information has already saved countless lives.

The Joint Commission's National Patient Safety Goals, implemented

in January 2003, set forth clear, evidence-based recommendations to focus

health care organizations on significant documented safety problems.

Accredited healthcare organizations that provide care relevant to the

goals are evaluated for compliance with these goals.

"There are considerable barriers to be overcome if we are to be

successful in persuading healthcare organizations and practitioners to

fully embrace state-of-the-art patient safety and health care quality

practices," says O'Leary. "The knowledge of what to do differently and how

to do it exists and progress is being made. However, more needs to be done

by all of us, including the Congress, if we are to succeed."

Source: JCAHO