Citations to IOM report


2000 Citations to the Institute of Medicine Report These are "leads" only - Contact publishers for full text.	http://md-jd.info http://md-jd.info/errors.htm

Other Years - Headlines: 1999.2000.2001.2002.2003
Other Years - Leads: 1999.2000.2001.2002.2003 (These are large files)

The Houston Chronicle
December 26, 2000, Tuesday 3 STAR EDITION
FOCUS: TREATING CHILDREN;
MEASURE OF SUCCESS;
Color-coded tape saves time, setting dosages at a glance
HICKORY, N.C.- A 5-year-old boy arrives in the emergency room, unconscious.
With no time to waste, doctors and nurses must guess his weight to get a proper dose of life-saving medicine.
That begins a hurried and complicated mathematical journey, converting pounds to kilograms, then multiplying and dividing milligrams and cubic centimeters. As seconds tick away, medical workers are guessing, too, which size tube to place into the boy's throat to open his airway and which size catheter to carry fluids through his small veins.
As an emergency physician at Lincoln County Hospital in the early 1980s, Dr. Jim Broselow worried about all the guesswork and arithmetic under pressure. "It was clear to me that I could screw up," he recalled. "When you do multiple calculations, you're going to make multiple errors."

Canada NewsWire
December 6, 2000, Wednesday
AUTROS Healthcare Solutions Secures $14 Million in First-Round Financing to Meet Growing Demand for Wireless Hospital Point-of-Care Solutions -- Funding from Institutional and Strategic partners will enable AUTROS to;
accelerate marketing and installation activities throughout North America and Europe --
AUTROS Healthcare Solutions, a worldwide
wireless point-of-care software solutions provider, today announced that it
has secured $14 million in special warrants led by Yorkton Securities, as well
as significant Mutual Funds, and a strategic investment partner holding a lead
position in a noteworthy US hospital group. These new funds will be used to
deliver AUTROS Healthcare Solutions' wireless medication management software
to healthcare facilities in North America, Europe, New Zealand and Australia.
Funding amounts are reported in Canadian dollars.
Joining the board of directors are Harvey Coleman, past president of DELL
Computers Canada and former Executive VP of GEAC; Jean Reeder, Ph.D., RN,
FAAN, recently retired Chief of Nursing for Toronto's Hospital for Sick
Children and a retired Colonel in the US Army Nursing Corps; Mr. Jeff Cohen,
LL.B., a partner with Torkin Manes Cohen & Arbus where he specializes in
mergers and acquisitions; and Mr. Eric Paul, president of AUTROS Healthcare
Solutions. Mr. Paul is a graduate pharmacist from the University of British
Columbia, and holds extensive experience in senior executive roles with some
of Canada's largest retail organizations.
Medical errors have become a global focus since the release of the 1999
Institute of Medicine Report stating that between 44,000 and 98,000 people die
each year in the United States from medical errors. AUTROS has seen orders
for their barcode technology increase exponentially worldwide in reaction to
this report. "We are focused on satisfying demand for the AUTROS Solution in
the United States, Canada, and the United Kingdom," says AUTROS Chairman and
CEO Norman Paul.

PR Newswire
December 6, 2000, Wednesday
AUTROS Healthcare Solutions Secures $14 Million in First-Round Financing to Meet Growing Demand for Wireless Hospital Point-of-Care Solutions;
--Funding from Institutional and Strategic partners will enable AUTROS to accelerate marketing and installation activities throughout North America and Europe --
AUTROS Healthcare Solutions, a worldwide wireless point-of-care software solutions provider, today announced that it has secured $14 million in special warrants led by Yorkton Securities, as well as significant Mutual Funds, and a strategic investment partner holding a lead position in a noteworthy US hospital group. These new funds will be used to deliver AUTROS Healthcare Solutions' wireless medication management software to healthcare facilities in North America, Europe, New Zealand and Australia. Funding amounts are reported in Canadian dollars.
Joining the board of directors are Harvey Coleman, past president of DELL Computers Canada and former Executive VP of GEAC; Jean Reeder, Ph.D., RN, FAAN, recently retired Chief of Nursing for Toronto's Hospital for Sick Children and a retired Colonel in the US Army Nursing Corps; Mr. Jeff Cohen, LL.B., a partner with Torkin Manes Cohen & Arbus where he specializes in mergers and acquisitions; and Mr. Eric Paul, president of AUTROS Healthcare Solutions. Mr. Paul is a graduate pharmacist from the University of British Columbia, and holds extensive experience in senior executive roles with some of Canada's largest retail organizations.
Medical errors have become a global focus since the release of the 1999 Institute of Medicine Report stating that between 44,000 and 98,000 people die each year in the United States from medical errors. AUTROS has seen orders for their barcode technology increase exponentially worldwide in reaction to this report. "We are focused on satisfying demand for the AUTROS Solution in the United States, Canada, and the United Kingdom," says AUTROS Chairman and CEO Norman Paul.

American Health Line
December 4, 2000
AMA: GROUP TO ADDRESS MEDICAL ERRORS AT CONFERENCE
In response to concerns over the increasing number of
medical errors, the American Medical Association this week will
consider a proposal that would create a national board to
investigate complaints, identify trends and recommend
"preventative measures," the Dallas Morning News reports. Last
year the Institute of Medicine reported that between 44,000 and
98,000 deaths occur each year because of errors at U.S.
hospitals. Under the AMA plan, the board would study medical
errors that are reported anonymously to a national databank.

Knight Ridder/Tribune News Service
The Charlotte Observer
December 2, 2000, Saturday
Color-coding for children saves precious time in emergency room
HICKORY, N.C. _ A 5-year-old boy arrives in the emergency room, unconscious.
With no time to waste, doctors and nurses must guess his weight to get a proper dose of life-saving medicine.
That begins a hurried and complicated mathematical journey, converting pounds to kilograms, then multiplying and dividing milligrams and cubic centimeters. As seconds tick away, medical workers are guessing, too, which size tube to place into the boy's throat to open his airway and which size catheter to carry IV fluids through his small veins.

The Buffalo News
November 29, 2000, Wednesday, FINAL EDITION
SEMINAR LOOKS TO REMEDY MEDICAL ERRORS
To cut down on medical errors, hospitals must change a culture that tends to sweep mistakes under the gurney, a leading safety expert suggested Tuesday.
Voluntary reporting of errors and taking responsibility for them were high on a list of challenges set out by Henry R. Manasse Jr., chairman of the National Safety Institute, at a seminar on "Errors in Medicine" in University Inn and Conference Center, Getzville.
"We need significant cultural changes to get people to talk about errors and make safety a high priority," Manasse told Kaleida Health administrators, physicians, clinical staff and board members at the session, sponsored by Kaleida and the University at Buffalo School of Medicine and Biomedical Sciences. When mistakes are made, he added, "Someone needs to come forward and take responsibility."

Canadian Business and Current Affairs
Medical Post
November 28, 2000
To err may be human, but that doesn't make it right: patient advocacy needed to cut out medical mistakes (Record in progress)
AMELIA ISLAND, FLA. -- Even for the chairmen of medical schools, getting a
family member with a serious illness quality medical care is difficult
according to a study presented here.
The study, presented at the North American Primary Care Research Group
(NAPCRG) annual meeting, asked high-profile and well-positioned doctors
across America if they experienced troubles with the care their family
members received.
The picture that emerged from their accounts is of a fragmented,
depersonalized and error-prone hospital environment that compromises
patient safety and cries out for strong patient advocacy.

TOPEKA CAPITAL JOURNAL
November 27, 2000, Monday
Learn from mistakes in Medical care
Being a doctor doesn't mean never having to say you are sorry.
When a medical mistake causes harm or even death, probably no one other than the victim or the victim's family feels worse than the medical practitioner involved in the incident.
Yet, no one may ever know that, for the fear of lawsuits has discouraged apologies or even full disclosure of what happened in some cases.

Scripps Howard News Service
November 22, 2000, Wednesday
Physician apologies could prevent lawsuits
Anyone who doubts that medicine is an error-ridden activity should look at the studies. Patients take a risk every time they see the doctor or enter the hospital. The best doctors and the top hospitals sometimes harm patients. Mistakes are as much a part of health care as they are in the rest of life.
A landmark 1999 Institute of Medicine study, although challenged and criticized, gave a glimpse of the problem. It estimated that 44,000 to 98,000 patients die from medical errors annually. That exceeds the 41,300 annual deaths from automobile accidents.

OB GYN News
November 15, 2000
Medication Errors Initiative Spotlights Physicians.
CHICAGO -- Physicians are deeply involved in the problem of medication errors and are a vital part of the solution, participants said at a meeting on patient safety sponsored by the National Patient Safety Foundation.
Medication errors have typically been associated with hospitals, blamed on overworked nurses, and considered the purview of credentialing organizations. But participants in the initiative heard evidence of significant physician involvement.
For example, a traditional approach to monitoring mistakes led Capital Health System to conclude that only 4% of the 339 medication errors that occurred in 1999 at its 589-bed hospital were due to prescribing errors.

Wisconsin State Journal
November 14, 2000, Tuesday, ALL EDITIONS
GOAL IS CUTTING MEDICAL ERRORS; 3 HOSPITALS AND OTHER HEALTH PROVIDERS HERE SET UP A CENTER ON PATIENT; SAFETY.
Five area health providers, including three hospitals, Monday unveiled a new center for patient safety in Madison and a joint commitment to reducing medication errors over the next three years.
The five providers will spend between $ 80,000 and $ 100,000 on the effort, which will collect information about hospital drug mistakes, the group said.

The Post and Courier (Charleston, SC)
November 5, 2000, Sunday, SUNDAY EDITION
Phobic fretting about death wastes precious living time
By Frank Wooten Scare tactics are taking a traumatizing toll on the American people.
No, not political scare tactics.
Though thoroughly unsettling to the readily deluded, the Gore campaign's preposterous alarms about George W. Bush - that he will loot Social Security and Medicare; foul the land, water and air; and exploit the downtrodden while lining the pockets of big-business barons - don't pack the permanent personal punch of a much more pervasive brand of fear-mongering.
Neither does the overblown news that Bush pleaded guilty to a misdemeanor DUI charge in Maine while Gerald Ford was president.

The Atlanta Journal and Constitution
November 2, 2000, Thursday, Home Edition
CRITICAL RN SHORTAGE: Georgia nurses say care suffers as load grows;
Low pay, overwork hurt morale
Many days, Melody Howarth says, "I feel like Lucy in the chocolate factory."
But instead of frantically packaging chocolates on a conveyor belt, as the " I Love Lucy" star did, Howarth shuttles among patients in an Atlanta hospital.
Howarth, a longtime registered nurse, blames managed care for her frustration with her workload. "Care at the bedside is not what it used to be, " she says. "Nurses are running around just putting out fires."

PR Newswire
November 2, 2000, Thursday
CSC and AUTROS Join Forces to Eliminate Medical Errors;
--Consulting and IT Firm to market AUTROS' Patient Safety Application --
Computer Sciences Corporation (NYSE: CSC) and AUTROS Healthcare Solutions have joined forces to combat and eliminate medical errors. Beginning today, CSC's Healthcare Group will market, sell and install the real-time, wireless, point-of-care AUTROS Medication Management System to its U.S. hospital clients.
"After an extensive review of point-of-care systems, we found AUTROS to be a technically savvy, complete and sound medication management system," said Judith Bachman, Principal, CSC Healthcare Group. "CSC is committed to improving the quality of care provided at our client hospitals and we do this by selecting the most current technology and management systems. Partnering with AUTROS affirms our ongoing commitment to make hospitals safer."
According to last year's Institute of Medicine Report, between 44,000 and 98,000 people die each year in the U.S. from medical errors. Of these deaths, 7,000 are caused by medication mistakes alone.
The AUTROS system allows physicians to order prescriptions using a device similar to a Palm Pilot; the program automatically checks for drug interactions and other possible errors, as well as correct dosage. This vital data is then transmitted in real-time to the hospital or local pharmacy, hospital nursing unit, home care or clinic. Before the administration of any medication, handheld scanning devices are used to access an electronic medication records database, the barcoded medication, and the patient's barcoded ID in order to confirm that the right patient receives the right medication and dose at the right time via the right route. After administration, medical and administrative records are automatically updated, eliminating time-consuming paperwork.

Nursing Management
November 1, 2000
Stop the rise in nursing errors--systematically.
In the past 5 years nationwide, at least 1,720 hospital patients were accidentally killed and 9,584 injured from RNs' actions or inaction.[1] The number of reported nursing errors in hospitals has increased in each of the past 5 years.[2] Even the American Hospital Association (AHA)--an organization not typically inclined to criticize hospitals--acknowledges that inadequate staffing and insufficient training are putting patients at risk.[3]
These alarming revelations appeared in the Chicago Tribune while the Institute of Medicine's (IOM) report is still fresh in our minds: Medical errors in U.S. hospitals kill between 44,000 and 98,000 people each year. Medication errors annually kill more than 7,000.[4]

PR Newswire
October 24, 2000, Tuesday
AUTROS Technology Extends to Hospitals Worldwide;
--Hospital becomes United Kingdom's first to use wireless bar-code technology for patient safety --
AUTROS Healthcare Solutions, a worldwide wireless point-of-care software solutions provider, announces that Southend Hospital in Essex, United Kingdom, will become the nation's first to install patient wireless barcode technology. Developed by Toronto-based AUTROS, and distributed throughout the U.K. by Medichain, this software system is currently being installed in hospitals worldwide as a means to track and monitor patient drug orders and ultimately eliminate medication errors.
Medical errors have become a global focus since the release of the 1999 Institute of Medicine Report stating that between 44,000 and 98,000 people die each year in the United States from medical errors. AUTROS has seen orders for their barcode technology increase exponentially worldwide in reaction to this report.
"Right now our systems are being installed in the United States, Canada, and the United Kingdom," says AUTROS Chairman and CEO Norman Paul. "There is a global momentum to eradicate medication errors and improve the quality of care that facilities provide and patients demand. We have multiple orders pending in point-of-care facilities worldwide and we continue to increase our staff to keep up with this demand."
Using the AUTROS computerized system, physicians can order prescriptions, IVs and TPNs using a wireless digital device similar to a Palm Pilot. The program automatically checks for drug interactions, correct dosage and other possible errors, then instantly transmits this vital data in real time to the hospital pharmacy, hospital nursing unit, home care unit or clinic.
Using a handheld scanning device, the nurse accesses the electronic medication records database, scans the barcoded medication and the patient's barcoded ID bracelet to confirm the right medication, dosage and time, as well as the correct route of administration, before administering any drugs.

Sun-Sentinel (Fort Lauderdale, FL)
October 24, 2000, Tuesday, Broward Metro EDITION
TRAGEDY TEACHES A LESSON: SHARING DATA SAVES LIVES;
FIVE YEARS AGO, A YOUNG BOY DIED FROM A MEDICINE MIX-UP. THE HOSPITAL'S;
CRUSADE TO HELP OTHERS AVOID THE SAME ERROR HAS WON PRAISE AS A MODEL.
Three syringes, two cups, and two glass vials: These are the items that killed a 7-year-old St. Lucie boy.
They sit in a small cardboard box within the Stuart office of Doni Haas, the retiring risk manager at Martin Memorial Hospital. She pulls them out in a grim show-and-tell to explain why medical mistakes should be studied, and their lessons shared.
"He was going in for simple ear surgery. We do it every day," Haas said. "Little kids just don't die from that."

Sun-Sentinel (Fort Lauderdale, FL)
October 22, 2000 , Sunday, Broward Metro EDITION
STUDY PUTS NUMBERS TOO HIGH, CRITICS SAY
Neither car accidents, nor breast cancer nor AIDS kills as many people each year as medical errors and negligent care.
At least, that's what some scholars think.
That stark comparison, released last December in the Institute of Medicine report, "To Err is Human: Building a Safer Health System," has touched off a controversy that continues to rage.

Business Wire
October 19, 2000, Thursday
AUTROS Healthcare Solutions Warns of 'Polypharmacy' Hazard During National Pharmacy Week
Acknowledging that this week is National Pharmacy Week in the United States, AUTROS Healthcare Solutions announces its concern over the issue of "polypharmacy," defined as a dangerous combination of prescription drugs that hurts a patient rather than helps him or her. AUTROS recognizes this problem and urges physicians and healthcare practitioners everywhere to be aware of potential interactions or side effects when prescribing. By gaining knowledge and adopting useful technology, medical professionals can begin to turn the polypharmacy issue around.

The Florida Times-Union (Jacksonville, FL)
October 16, 2000 Monday, City Edition
HEALTH CARE Numbers game
Last week, TV network news reprised what is fast becoming an urban legend: the vast killing grounds in the nation's hospitals.
Unquestionably shaky numbers have taken on the form of doctrine now, contributing to efforts to build a federal government complex so huge it will not only eat any budget surplus for the next decade, but require huge new tax increases in addition.
You know the drill. Between 44,000 and 98,000 people are killed each year by medical mistakes. This finding is attributed to the Institute of Medicine.

The San Francisco Chronicle
OCTOBER 16, 2000, MONDAY, FINAL EDITION
LETTERS TO THE EDITOR

The Irish Times
October 9, 2000
Watching out for medical mistakes is vital
Errors in health care are more common than patients might think. They certainly occur more often than doctors would like, and, as the human element is unlikely to be removed from the caring process, errors are likely to persist.
Medical errors are responsible for preventable injury in as many as one out of every 25 hospital patients, according to a recent report by the Institute of Medicine in the US. The IOM report estimates that between 44,000 and 98,000 people die each year from medical errors. Even taking the lower figure means that medical error is the eighth leading cause of death in the United States. Clearly, some effort needs to be directed at reducing these figures. Otherwise a genuine fear of "the cure being worse than the disease" could affect patients' confidence and their willingness to undergo treatment.

The Atlanta Journal and Constitution
October 4, 2000, Wednesday, Home Edition
Medicare study ranks Ga. 47th in care methods
A first-of-its-kind broad study of how medical treatment standards are followed for Medicare patients ranks Georgia 47th in performance among the 50 states, the District of Columbia and Puerto Rico.
The study, released Tuesday by the Health Care Financing Administration, which runs the federal Medicare program, used data from medical charts, billing records and patient surveys from 1997 to 1999 to track how states follow accepted clinical guidelines.
Other Southeastern states also fared poorly in the rankings, which studied 22 treatment and prevention measures for heart attack, heart failure, stroke, pneumonia, diabetes and breast cancer. Those conditions account for at least 25 percent of admissions of Medicare patients to Georgia hospitals.

Drug Topics
October 2, 2000
Task force starts shaping research to cut med errors; Brief Article
The first national summit on medical errors and patient safety was held in Washington, D.C., last month. Its aim was to begin setting a coordinated research agenda to help reduce mistakes by 50% in five years. That's the goal set last year by the Institute of Medicine in its landmark report, To Err Is Human. The report said evidence suggests 44,000 to 98,000 Americans die each year as a result of preventable medical mistakes, including as many as 7,000 from prescription drug errors. The cost to the nation's health-care system was put at as much as $ 8.8 billion annually.

Business & Health
October 1, 2000
How a bill doesn't become a law; Brief Article
Last November, the prestigious Institute of Medicine released its now famous report estimating that medical errors kill between 44,000 and 98,000 Americans each year. Congress was out of session, but lawmakers reacted with surprising speed.
Within hours, it seemed, Sen. Edward Kennedy (D-Mass.) vowed to introduce legislation to implement the IOM's recommendations, which included a new "Center for Patient Safety" within the Department of Health and Human Services and mandatory and voluntary systems for reporting errors. "We must make patient safety a national priority," said Kennedy.

Journal of the Society of Pediatric Nurses
October 1, 2000
Benchmarking: What's in It for Nurses?
Scientific Inquiry provides a forum to facilitate the ongoing process of questioning and evaluating practice, presents informed practice based on available data, and innovates new practices through research and experimental learning.
Benchmarking is a term whose origins are obscure but which has become a focal point in outcomes based research. Initially "benchmark" meant "a mark on a permanent object indicating elevation and serving as a reference in topographical surveys and tidal observations" (Webster, 1988, p. 143). The definition has evolved to mean "something that serves as a standard by which others may be measured" (Webster). Benchmarking is about comparisons. When we rank athletes, we might compare one runner's performance to another's. Athletes study their performance so that they can learn and improve. Health care is beginning to follow their example.
Evidence-based decisions are becoming a driving force in healthcare research. Benchmarking is a method of collecting and monitoring key indicators that are reflective of an organization's clinical and operational performance. Additionally, external comparison groups provide an opportunity to learn from the expertise of others, to avoid making the same mistakes or "reinventing the wheel."

University Wire
September 28, 2000
Good business, bad medicine
Millions of Americans are confident they are receiving the best, most advanced health care in the world from their hospitals.
Although the United States may lead the medical world in terms of technology and research, the nation is lagging far behind in the most important area -- competent medical staffers.
In a report released by The Chicago Tribune, at least 1,720 patients have died in U.S. hospitals since 1995 due to mistakes made by overwhelmed or ill-prepared registered nurses.
This report, which also claims that more than 9,500 patients have been injured, follows a 1999 report by the Institute of Medicine that reported that anywhere from 44,000 to 98,000 Americans die in hospitals every year due to mistakes made by hospitals, clinics and pharmacies.

Federal News Service
September 20, 2000, Wednesday
PREPARED STATEMENT OF PATRICK J. CLEARY THE NATIONAL ASSOCIATION OF MANUFACTURERS
BEFORE THE HOUSE COMMERCE COMMITTEE
SUBJECT - THE PATIENT PROTECTION ACT
The NAM strongly supports the Patient Protection Act of 2000 and urges this committee and Congress to act swiftly to pass it before the 106th Congress adjourns sine die. Passage of this legislation to provide public access to the National Practitioner Data Bank would give health care consumers an important tool to evaluate perspective physicians and to guard against the rare dangerous or incompetent physician. This legislation is consistent with employers' longstanding efforts to improve health care quality by providing health care purchasers and consumers with better information. A recent Institute for Medicine report revealing that 44,000 - 98,000 people die each year as a consequence of medical errors illustrates the extent of the threat faced by health care consumers, who deserve the best possible protections. Present measures to deter medical errors - medical malpractice lawsuits and disciplinary proceedings by state boards of medical licensure have proven ineffective to deter medical errors. The Patient Protection Act will supplement not supplant state disciplinary proceedings. In recognition of concerns that have been raised on the readiness of the Data Bank for public disclosure, a limited delay to improve the Data Bank may increase the confidence of consumers and providers alike.
*****
STATEMENT OF THE NATIONAL ASSOCIATION OF MANUFACTURERS REGARDING THE PATIENT PROTECTION ACT BEFORE THE COMMERCE COMMITTEE OF THE U.S. HOUSE OF REPRESENTATIVES SEPTEMBER 20, 2000

Federal News Service
September 20, 2000, Wednesday
PREPARED TESTIMONY OF TRAVIS B. PLUNKETT LEGISLATIVE DIRECTOR CONSUMER FEDERATION OF AMERICA
BEFORE THE HOUSE COMMERCE COMMITTEE
SUBJECT - PUBLIC ACCESS TO THE NATIONAL PRACTITIONER DATA BANK
Good morning. My name is Travis Plunkett and I am the legislative director of the Consumer Federation of America.1 I appreciate the opportunity to offer my comments today in strong support of H.R. 5122, which would allow the American public access to information in the National Practitioner Data Bank about physicians' licensure, disciplinary and medical malpractice history. I also offer this testimony on behalf of two other national organizations, Consumers Union/2 and the Center for Medical Consumers.3
I would like to commend Chairman Bliley for introducing this important legislation, and Congressmen Dingell, Upton and Stupak for the significant work that they have done in thoroughly evaluating the potential consequences of such a move. The comprehensive and balanced hearings that have been held by the Commerce Committee's Subcommittee on Oversight and Investigations on this issue have set the stage for timely passage of H.R. 5122. There is a very simple reason why the consumer community is united in support of opening up the National Practitioner Data Bank to the public. This taxpayer-financed database provides crucial information that consumers can use, in conjunction with other sources of information, to choose the right physician and protect themselves from dangerous providers.

Federal Document Clearing House Congressional Testimony
September 20, 2000, Wednesday
COMMITTEE: HOUSE COMMERCE
TESTIMONY PUBLIC ACCESS TO NATIONAL PRACTITIONER DATA BANK
September 20, 2000 Prepared Statement of Mr. Patrick Cleary Vice President for Human Resource Policy National Association of Manufacturers 1331 Pennsylvania Avenue, N.W., Suite 600 Washington, DC 20004 Panel 3, Witness 4 Mr. Chairman, on behalf of the more than 14,000 members of the National Association of Manufacturers, I would like to commend you for introducing the Patient Protection Act of 2000. The NAM strongly supports your bill to provide consumers access to detailed information on their physicians. We commend you for working to lift the public veil on the National Practitioner Data Bank. The National Association of Manufacturers - 18 million people who make things in America - is the nation's largest and oldest multi- industry trade association. The NAM represents 14,000 member companies (including more than 10,000 small and mid-sized manufacturers) and 350 member associations serving manufacturers and employees in every industrial sector and all 50 states. Headquartered in Washington, D.C., the NAM has 10 additional offices across the country. Improving Health Care Quality NAM members are strongly committed to providing health care benefits to their workers and their workers' dependents. Indeed, 98 percent of NAM members provide health benefits to their workers and dependents. Our members have always worked to ensure that workers and manufacturers receive the best quality care for their health care dollar. Employers have helped drive the quality revolution through such entities as the National Center for Quality Assurance, URAC / The American Accreditation HealthCare Commission and the Foundation for Accountability (FACCT).

Employee Benefit News
September 15, 2000
Academics to tackle medical errors cause
Editorial Staff
Aetna U.S. Healthcare and the Aetna Foundation in August awarded $840,000 in grants to five academic institutions in order to study how to reduce the incidence of medical errors.
The Institute of Medicine (IOM) reported last year that the number of medical errors each year numbered between 44,000 and 98,000 deaths, a number that has since been disputed by some physicians.

Global News Wire
Business Line
September 13, 2000
FT-ACC-NO: A200009131AB4-CB-WR
INDIA: MEDICAL MISTAKES
IN whatever way the controversy over the untimely death of the Minister of Power, Rangarajan Kumaramangalam, is resolved after the submission of the report of the inquiry committee set up by the Central Government, there is no question at all that medical establishments and individual doctors and nurses, like all human beings, are liable to make mistakes.
Only, the consequences for the patients in the case of serious illnesses or major operations, turn out to be grave, and sometimes deadly.
The situation is made all the worse by the hospitals and the doctors concerned showing reluctance, if not resistance, to give out full information on the nature of the ailment, condition of the patient and the prognosis. In many hospitals, patients and their relatives are rebuffed gruffly if they ask questions, or if they demand records of course of treatment. It is not uncommon to see deeply worried relatives running after doctors or nurses who walk on hurriedly and impatiently, totally ignoring them.

BUSINESS LINE
September 13, 2000
India: Medical mistakes
IN whatever way the controversy over the untimely death of the Minister of Power, Rangarajan Kumaramangalam, is resolved after the submission of the report of the inquiry committee set up by the Central Government, there is no question at all that medical establishments and individual doctors and nurses, like all human beings, are liable to make mistakes.
Only, the consequences for the patients in the case of serious illnesses or major operations, turn out to be grave, and sometimes deadly.
The situation is made all the worse by the hospitals and the doctors concerned showing reluctance, if not resistance, to give out full information on the nature of the ailment, condition of the patient and the prognosis. In many hospitals, patients and their relatives are rebuffed gruffly if they ask questions, or if they demand records of course of treatment. It is not uncommon to see deeply worried relatives running after doctors or nurses who walk on hurriedly and impatiently, totally ignoring them.

Medical Industry Today
September 13, 2000, Wednesday
Federal Task Force Aims to Reduce Medical Errors
Representatives from healthcare providers and purchasers gathered Monday to discuss research initiatives aimed at reducing the number of medical errors in the United States each year.
The National Summit on Medical Errors and Patient Safety Research, sponsored by the Agency of Healthcare Research and Quality (AHRQ), was held in Washington, D.C.
AHRQ, which is part of the Quality Interagency Coordination Task Force, is responsible for reducing medical mistakes in the United States, after a November 1999 report by the Institute of Medicine (IOM) suggested that the number of medical errors was too high, according to a Reuters Health report.
According to the IOM report, between 44,000 and 98,000 people die as a result of medical errors each year--costing the nation's healthcare system an estimated $8.8 billion annually. The institute stated that more people die from medical mistakes annually than from highway accidents, breast cancer or AIDS, Medical Industry Today reported earlier.

Newsday (New York, NY)
September 12, 2000, Tuesday NASSAU AND SUFFOLK EDITION
HEALTH-CARE LEADERS TARGET MEDICAL ERRORS
Washington-Acknowledging that preventable medical errors kill more Americans every year than breast cancer, AIDS or car accidents, a panel of public and private leaders met yesterday to set a national agenda to improve patient safety.
"We need to treat medical errors like an epidemic of a disease," said Dr. John Eisenberg, director of the federal Agency for Healthcare Research and Quality and the convenor of the 17-member panel. "The first thing we have to do is to understand how big a problem it is and whom it's affecting. The second thing is to understand what the causes are and the third is to develop a solution.

American Health Line
September 11, 2000
MEDICAL ERRORS: NURSING ERRORS KILL, INJURE THOUSANDS
"Overwhelmed and inadequately trained" nurses kill and injure thousands of patients annually, while hospitals continue to cut staffing and slash budgets, a Chicago Tribune investigation found. Part one in a three-part series reported that, since 1995, registered nurses nationwide have accidentally killed more than 1,720 patients and injured 9,584 others. Although registered nurses serve as the "primary sentinels" of health care, a majority of hospitals have eliminated or replaced the role of their "best-trained, highest-paid" nurses, creating a "harried" work environment that often endangers patients. The Tribune examined three million state and federal records -- including FDA and HHS reports, federal and state hospital surveys and complaint investigations, court and private health care files and state nurse disciplinary records -- to uncover the "hidden role registered nurses play in medical errors."

Business Wire
September 11, 2000, Monday
Physicians Across the Nation Reduce Medical Errors With e-Prescribing Technology; Doctors Select ePhysician's Wireless Handheld Device as Product of Choice
WHAT: Thousands of physicians nationwide are already working to reduce medical errors by using ePhysician, a wireless, secure handheld device, to electronically send prescriptions through the Internet to the pharmacy.
WHO: Doctors across the United States use ePhysician to access a suite of services to prescribe medication, schedule patients and view allergy, drug coverage and critical patient information anytime, anywhere.
WHY: Medical officials are meeting today for the National Summit on Medical Errors and Patient Safety Research which will address The National Academy of Sciences' Institute of Medicine report which estimates that between 44,000 and 98,000 people die annually because of medical errors. Medication errors often occur because of illegible handwriting, confusing drug names and dosage mistakes, which cause problems for physicians, pharmacists and patients across the nation. When physicians prescribe electronically, the rate of Adverse Drug

AAP NEWSFEED
September 10, 2000, Sunday
World News In Brief
WORLD DATELINES

Chattanooga Times / Chattanooga Free Press
September 10, 2000, Sunday
Nursing mistakes blamed for deaths
CHICAGO -- Poorly trained or overwhelmed nurses are responsible for thousands of deaths and injuries each year in the nation's hospitals, according to a report published in the Sunday edition of the Chicago Tribune.
Since 1995, at least 1,720 hospital patients have died and 9,548 others have been injured because of mistakes made by registered nurses across the country, the Tribune found in an analysis of 3 million state and federal records.
The records include cases of patients getting overdoses of medication, vital care being delayed for hours and nurses performing medical procedures without proper training.

CNN
SHOW: CNN SUNDAY MORNING 08:00
September 10, 2000; Sunday
Investigation Blames Nursing Crisis for Thousands of Deaths and Injuries
LEAD:
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MILES O'BRIEN, CNN ANCHOR: Turning now to your health. A disturbing report blames poorly trained and overworked nurses for thousands of hospital deaths and injuries. A "Chicago Tribune" investigation found since 1995 at least 1,720 hospital patients have died because of mistakes made by registered nurses across the country. More than 9,000 others have been injured, says the report. The "Chicago Tribune" says it has, its investigation is based on an analysis of three million state and federal records. It comes on the heels of a broader report by the Institute of Medicine, which estimates medical mistakes kill at least 44,000 hospital patients a year nationwide.

The Commercial Appeal (Memphis, TN)
September 10, 2000, SUNDAY, FINAL EDITION
REPORT LINKS STRESSED NURSES TO DEATHS, INJURIES
Poorly trained or overwhelmed nurses are responsible for thousands of deaths and injuries each year in the nation's hospitals, according to a Chicago Tribune investigation.
Since 1995, at least 1,720 hospital patients have died and 9,548 others have been injured because of mistakes made by registered nurses across the country, the Tribune found in an analysis of 3 million state and federal records.
The records include cases of patients getting overdoses of medication, vital care being delayed for hours and nurses performing medical procedures without proper training.

Dayton Daily News
September 10, 2000, Sunday,
REPORT SAYS BAD NURSING KILLS PATIENTS
CHICAGO - Poorly trained or overwhelmed nurses are responsible for thousands of deaths and injuries each year in the nation's hospitals, according to the Chicago Tribune.
Since 1995, at least 1,720 hospital patients have died and 9,548 others have been injured because of mistakes made by registered nurses across the country, the Tribune found in an analysis of 3 million state and federal records published in today's editions.

The Florida Times-Union (Jacksonville, FL)
September 10, 2000 Sunday, City Edition
Nursing mistakes kill thousands of patients Safety compromised as hospitals cut back
CHICAGO -- Overwhelmed and inadequately trained nurses kill and injure thousands of patients every year as hospitals sacrifice safety for an improved bottom line, a Chicago Tribune investigation has found.
Since 1995, at least 1,720 hospital patients have died and 9,548 others have been injured because of mistakes made by registered nurses across the country, the Tribune found in an analysis of 3 million state and federal records. The analysis is published in today's Tribune.

Pittsburgh Post-Gazette
September 10, 2000, Sunday, TWO STAR EDITION
NO HEADLINE
NURSES' ERRORS LEAD TO DEATHS
CHICAGO -- Poorly trained or overwhelmed nurses are responsible for thousands of deaths and injuries each year in the nation's hospitals, according to a Chicago Tribune investigation.
Since 1995, at least 1,720 hospital patients have died and 9,548 others have been injured because of mistakes made by registered nurses across the country, the Tribune found in an analysis of 3 million state and federal records.
The records include cases of patients getting overdoses of medication, vital care being delayed for hours and nurses performing medical procedures without proper training.

The Washington Post
September 10, 2000, Sunday, Final Edition
NATION IN BRIEF
Nursing Mistakes
Blamed for Deaths

CHICAGO--Poorly trained or overwhelmed nurses are responsible for thousands of deaths and injuries each year in the nation's hospitals, according to a Chicago Tribune investigation.
Since 1995, at least 1,720 hospital patients have died and 9,548 others have been injured because of mistakes made by registered nurses across the country, the Tribune found in an analysis of 3 million state and federal records.
The records include cases of patients receiving overdoses of medication, vital care being delayed for hours and nurses performing medical procedures without proper training.

Business Wire
September 7, 2000, Thursday
American Re HealthCare and DoctorQuality.com Form Alliance; Combined Effort to Combat the Human and Financial Costs of Medical Errors
American Re HealthCare, an industry leader in predicting, preventing and protecting against catastrophic healthcare risk, and DoctorQuality.com, a leading Internet-based healthcare quality and patient safety company, announced an alliance today. The focus of the collaboration will be to work with various re-insurance clients, employers, insurers, and health systems to develop and provide integrated solutions to both reduce costs and improve quality in healthcare by reducing medical errors.
According to the Institute of Medicine's report published in November last year, To Err is Human: Building a Safer Health System, 44,000 to 98,000 people die each year from medical errors that occur in hospitals. The national cost of preventable errors that result in injury are between $17 billion and $29 billion, the report estimated. "American Re HealthCare's strategy has been to help our clients to predict, prevent and protect against catastrophic health events, which include the kinds of medical errors referred to in the IOM report," say Dr. James B. Couch, vice president of strategic development of American Re HealthCare.

Business Wire
September 5, 2000, Tuesday
ePhysician: Secure Wireless Technology Reduces Medical Errors; Handheld Device Enables Physicians to Send Prescriptions Through the Internet to the Pharmacy
WHAT: The National Summit on Medical Errors and Patient Safety Research is meeting on Sept. 11 to address The National Academy of Sciences' Institute of Medicine report entitled "To Err Is Human: Building a Safer Health System." The report estimates that between 44,000 and 98,000 people die annually because of medical errors. The summit's goal is to increase patient safety in hospitals, nursing homes, physicians' offices and medical clinics.

Clinician Reviews
September 1, 2000
RESEARCHERS DISPUTE RECENT MEDICAL ERROR DATA.
New light has been shed on the widely publicized and debated Institute of Medicine (IOM) report on deaths caused by medical errors. The IOM report, which suggested that 44,000 to 98,000 deaths occur annually in the United States as a result of medical error, caused upset and upheaval throughout the medical community. Two editorials in a recent issue of JAMA take a closer look, with their authors reaching quite different conclusions.

Family Practice News
September 1, 2000
AOA Dues Increase to Fund Public Education Campaign; American Osteopathic Association; Brief Article
CHICAGO -- The American Osteopathic Association's "unity" campaign appears to have instilled solidarity within the group; AOA's 430-member House of Delegates voted unanimously to approve a 20% dues increase at its annual meeting.
The AOA launched the "unity" campaign 2 years ago to rally together disparate groups within the house of osteopathic medicine and bolster the public and professional image of osteopathic physicians.
Full membership dues in 2001 will climb $ 100 (to $ 590); new physicians, students, military, and other categories of physicians will see smaller increases. This is the AOAs first dues increase in 5 years; 17% of the new funds are earmarked for the unity push, a $ 2-million consumer advertising campaign.

FDA Consumer
September 1, 2000
MAKE NO MISTAKE!: Medical Errors Can Be Deadly Serious; an estimated 44,000-98,000 Americans die annually due to preventable medical errors
Two months after a double bypass heart operation that was supposed to save his life, comedian and former Saturday Night Live cast member Dana Carvey got some disheartening news: the cardiac surgeon had bypassed the wrong artery. It took another emergency operation to clear the blockage that was threatening to kill the 45-year-old funnyman and father of two young kids.
Responding to a $ 7.5 million lawsuit Carvey brought against him, the surgeon said he'd made an honest mistake because Carvey's artery was unusually situated in his heart. But Carvey didn't see it that way: "It's like removing the wrong kidney. It's that big a mistake," the entertainer told People magazine.
Based on a recent report on medical mistakes from the National Academy of Sciences' Institute of Medicine, Carvey might fairly be characterized as one of the lucky survivors. In its report, To Err Is Human: Building a Safer Health System, the IOM estimates that 44,000 to 98,000 Americans die each year not from the medical conditions they checked in with, but from preventable medical errors.

Nursing Management
September 1, 2000
Nurses--yes, nurses--improve physician order entry; Brief Article
The centuries-old words of Greek dramatist Euripides sum up what we've learned about orders and outcomes: "A bad beginning makes a bad ending."
Think about it. Physician orders initiate clinical interventions, which then produce outcomes. Some estimate that order entry is where 80% of medication errors occur. So if we can proactively influence physician orders, we can influence patient outcomes.

OB GYN News
September 1, 2000
Medical Mistakes?
I really don't understand it: Physicians love to nit-pick the printed word. In fact, we thrive on it. If you publish a study on diabetes, thousands of doctors across the country will tear it apart, mercilessly, word by word, line by line, chapter and verse. That's what keeps the science valid.
Yet if you publish a study accusing the medical profession of killing hundreds of thousands of patients, the same physicians will react with a collective yawn. Never--not once--do they ask, "Where's the beef?"

THE SATURDAY OKLAHOMAN
August 19, 2000, Saturday CITY EDITION
Mistake leads hospitals to change policy Integris-owned medical centers to mark surgical patients
Two Oklahoma City hospitals owned by Integris Health have
implemented a policy of marking the surgery site on a patient's
body after a surgeon operated on the wrong area.
Damon Gardenhire, spokesman for Integris Health, said a "wrong
site surgery" occurred this summer at one of its Oklahoma City
hospitals. Integris Health owns Baptist Medical Center and
Southwest Medical Center.

The Stuart News/Port St. Lucie News (Stuart,FL)
August 16, 2000, Wednesday
DOCTORS ARE RISKIER THAN MOTORCYCLES
Editor:
Now that the no-helmet law is in effect, we soon shall hear from the medical community. For years they have claimed that motorcyclists riding without helmets are a huge public burden to taxpayers because of medical costs, but the truth comes out in a front-page article in USA Today entitled "Medical Mistakes 8th Top Killer."
The Nov. 30, 1999 article claims that medical errors kill more people in the U.S. than traffic accidents, breast cancer or AIDS. Between 44,000 and 98,000 Americans die each year from medical mistakes, making this the eighth leading cause of death and resulting in costs of over $8.8 billion a year.

Business Insurance
August 14, 2000, Monday
Updates

PR NEWSWIRE
August 10, 2000
Aetna U.S. Healthcare(R) Announces $ 840,000 in Research Grants Focused on Studying and Reducing Medical Errors

Research Ranging From Improving Medication Safety To Controlling Infection in Long-Term Care Facilities
BLUE BELL, Pa., Aug. 10 /PRNewswire/ -- Aetna U.S. Healthcare and the Aetna Foundation today announced an important step in the national campaign against medical error -- $ 840,000 in grants to researchers at five leading academic institutions to study issues such as reducing medication errors, controlling infection in long-term care facilities, and improving safety for surgical patients.
According to a 1999 Institute of Medicine (IOM) report, medical errors account for between 44,000 and 98,000 deaths each year in the United States. The IOM study caused a surge of public interest in the topic and led to a Presidential Order to attack the issue. In response to the report, Aetna U.S. Healthcare announced in January that it would devote up to $ 1 million to fund original research to develop and evaluate strategies to reduce medical errors. As a result, five grants were awarded today by the Aetna Quality Care Research Fund. The grants will be administered by the Academic Medicine and Managed Care Forum ("Forum"), an alliance of 51 academic medical centers and teaching hospitals, pharmaceutical companies and Aetna U.S. Healthcare.

PR Newswire
August 10, 2000, Thursday
Aetna U.S. Healthcare(R) Announces $840,000 in Research Grants Focused on Studying and Reducing Medical Errors;
Research Ranging From Improving Medication Safety To Controlling Infection in Long-Term Care Facilities
Aetna U.S. Healthcare and the Aetna Foundation today announced an important step in the national campaign against medical error -- $840,000 in grants to researchers at five leading academic institutions to study issues such as reducing medication errors, controlling infection in long-term care facilities, and improving safety for surgical patients.
According to a 1999 Institute of Medicine (IOM) report, medical errors account for between 44,000 and 98,000 deaths each year in the United States. The IOM study caused a surge of public interest in the topic and led to a Presidential Order to attack the issue. In response to the report, Aetna U.S. Healthcare announced in January that it would devote up to $1 million to fund original research to develop and evaluate strategies to reduce medical errors. As a result, five grants were awarded today by the Aetna Quality Care Research Fund. The grants will be administered by the Academic Medicine and Managed Care Forum ("Forum"), an alliance of 51 academic medical centers and teaching hospitals, pharmaceutical companies and Aetna U.S. Healthcare.
"As the IOM study indicates, patient safety is a critical issue that the health care community must expand its efforts to address. Aetna U.S. Healthcare has a tremendous opportunity to play a role in this important national initiative through our activities as the nation's leading health insurer and a funder of outcomes-based research," said John T. Kelly, M.D., Aetna U.S. Healthcare's director of physician relations. "We're pleased that researchers at some of the nation's leading academic institutions have agreed to undertake research into how and why medical errors happen, so that we can make progress in preventing avoidable complications."

Copley News Service
August 9, 2000, Wednesday
''Assignment Illinois'' column
A Florida doctor cut into the wrong side of a patient's brain. A South Carolina physician used an amputated foot in a crab trap.
An Illinois doctor at first refused a patient's request for a biopsy of a breast lump that later proved to be cancerous.
The three are among 20,125 ''questionable doctors'' listed in the latest edition of a consumer guide published by Public Citizen.

Copley News Service
August 9, 2000, Wednesday
ASSIGNMENT ILLINOIS
A Florida doctor cut into the wrong side of a patient's brain. A South Carolina physician used an amputated foot in a crab trap.
An Illinois doctor at first refused a patient's request for a biopsy of a breast lump that later proved to be cancerous.
The three are among 20,125 ''questionable doctors'' listed in the latest edition of a consumer guide published by Public Citizen.

The Washington Post
August 9, 2000, Wednesday, Final Edition
'Medical Mistakes'
Newt Gingrich, in his Aug. 2 op-ed article, "Medical Mistakes," says, "The time has come for Congress and the president to act . . . and to stop defending inefficiency." Mr. Gingrich should have examined the record.
Before the Institute of Medicine issued its report on medical errors, the president had established the Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Following its report in December, President Clinton issued a call to action on the quality of health care and medical errors. As a result, the federal Quality Improvement Coordination task force was created and has developed plans and funded activities. Its program includes the creation of a new center for patient safety, a requirement that each of the 6,000 hospitals participating in Medicare have error-reduction programs in place, a mandatory reporting system in the 500 military hospitals and clinics, and a phased-in nationwide state-based system of mandatory and voluntary error reporting.

BestWire
August 08, 2000
INSURERS REACT TO MEDICAL ERRORS DEBATE
Oldwick N.J. (BestWire) - In the two decades before he became vice president of strategic development for American Re-Insurance's Health Care division, Dr. James B. Couch practiced medicine, defended doctors and hospitals in medical-malpractice lawsuits and served as medical director in charge of quality management for two large health insurers. "During that time, I saw hundreds if not thousands of medical errors occur because of systemic problems," Couch said. When Couch, who holds degrees in medicine and law, began working with American Re three years ago to develop the company's health-care strategy, he pressed the idea that the reinsurer could distinguish itself and reduce its loss ratio if it focused on preventing medical errors and resulting catastrophic health events. American Re HealthCare, Princeton, N.J., had been working for several years on its medical error-reduction strategy when the prestigious Institute of Medicine issued a report that pushed the project into high gear. Published in November, "To Err Is Human: Building a Safer Health System" turned a spotlight on the health-care industry's disastrous record concerning medical errors, including stunning and controversial statistics that 44,000 to 98,000 people die each year from medical errors that occur in hospitals. The report emphasized that most errors are induced by faulty systems, and it highlighted the need for dramatic, systemwide changes including mandatory reporting of errors and safety systems designed to prevent, detect and minimize hazards and the likelihood of errors. "The Institute of Medicine report really galvanized our efforts to develop and implement a strategy geared toward predicting, preventing and protecting against the potentially catastrophic impact of medical errors," Couch said.

The Bulletin's Frontrunner
August 2, 2000
Report On Medical Errors Likely To Lead To Boost In Research Funds.
CQ (8/1, Adams) reported Institute of Medicine President Kenneth Shine, "who last year oversaw the production of an influential report on medical errors, said today that patient safety advocates are 'virtually certain' to get more money for research from this year's appropriations cycle." The House and Senate versions "of the fiscal 2001 spending bill for the departments of Labor, Health and Human Services and Education (HR 4577) include increases of $20 million and $50 million, respectively, for the Agency for Healthcare Research and Quality to boost research on patient safety." Shine " predicted the final figure will be close to $50 million, enough to support a range of demonstration projects." CQ added, "Last year's IOM report said medical mistakes cause between 44,000 and 98,000 deaths a year. Errors ranged from surgeries on the wrong body part to the more common use of incorrect medicine." The report "touched off a public furor and inspired various bills intended to boost patient safety, but lawmakers have deadlocked over accountability for medical mistakes. As a result, more research funding is likely to be the only legislative response to the problem."

Best's Review
August 1, 2000
Safety Measures.
A national debate on medical errors highlights insurers' role in reducing tragedies--and claims.
In the two decades before he became vice president of strategic development for American Re-Insurance's Health Care division, Dr. James B. Couch practiced medicine, defended doctors and hospitals in medical-malpractice lawsuits and served as medical director in charge of quality management for two large health insurers.
"During that time, I saw hundreds if not thousands of medical errors occur because of systemic problems," Couch said. When Couch, who holds degrees in medicine and law, began working with American Re three years ago to develop the company's health-care strategy, he pressed the idea that the reinsurer could distinguish itself and reduce its loss ratio if it focused on preventing medical errors and resulting catastrophic health events.

Better Homes and Gardens
August 1, 2000
Measure Twice, Cut Once: How To Avoid Medical Errors.
Vickie Wakefield, an 82-year-old suffering from carpal tunnel syndrome, needed surgery. So her daughter, Mary Wakefield, took her to the hospital for the medical procedure. When it was over, the surgeon called Mary to say that the operation on her mother's right wrist went just fine.
There was just one problem: The surgery should have been performed on her mother's left wrist.
The medical mishap occurred last September, while Mary Wakefield--a professor of nursing at George Mason University, in Fairfax, Virginia, and an expert on health care policy--was helping to write To Err Is Human: Building a Safer Health System. This report, published by the Institute of Medicine late last year, describes the sad frequency at which patients in the American medical system fall victim to mistakes.

Health Management Technology
August, 2000
Alerting Staff to Medication Errors
According to the Institute of Medicine's (IOM) report, To Err Is Human: Building a Safer Health System, between 44,000 and 98,000 people die each year as the result of clinical errors. Of course, any unnecessary loss of life is an undeniable tragedy. In addition, the problem of clinical errors increases the cost of healthcare delivery by causing unnecessary complications that increase length of stay and resource consumption. Further, it can be damaging to staff morale and have a negative impact on caregiver recruitment and retention.

Health Services Research
August 1, 2000
Medical Errors and Patient Safety: A Growing Research Priority.
One death from a medical error is too many; 44,000 deaths annually constitute a national problem of epidemic proportion. Although our medical profession is world class and our technology the most advanced, Americans are dying or suffering needless injuries in the course of receiving healthcare. These were among the findings of last year's report by the Institute of Medicine (IOM): To Err is Human: Building a Safer Health System. Not surprisingly IOM's report generated tremendous interest among the media and the public at large, on Capitol Hill, and within the health industry. It also set into motion a series of hearings and public policy discussions underscoring the need for coordinated activities aimed at improving patient safety.
In the ten months since To Err is Human, the Agency for Healthcare Research and Quality (AHRQ) has been at the forefront of several initiatives. As this article goes to press, a call for new research to test methods of measuring and reducing medical errors has been released and a national summit is being planned to help further define the research agenda in this area. However, much remains to be done, and there are many ways in which the health services research community can and should be involved.

RN
August 1, 2000
Preventing medical mistakes.
In the aftermath of the recent federal report detailing the extent of medical errors, healthcare is focused on improving the statistics. The route chosen by one Florida hospital-which wound up in the national spotlight after a devastating treatment error-could serve as a blueprint for others. The key: Concentrate on fixing the system rather than blaming people for errors.
KEY WORDS
* medical errors
* reporting
* organizational culture
* data collection
* data analysis
* computer software
* wrong-site surgery
* medication errors
* patient falls
* treatment delays
* ulcer formation
Last fall, the Institute of Medicine released a report that sent both the public and healthcare professionals into a frenzy. The findings: Medical errors kill between 44,000 and 98,000 people in U.S. hospitals each year. [1] The widespread concern about patient safety--and the media attention the report has generated--is nothing new to us. Five years ago, one of a series of highly publicized mistakes occurred at the hospital where I work, University Community Hospital (UCH) in Tampa, Fla. It involved a patient whose right leg was scheduled to be surgically amputated. His left leg was taken off instead.

Business Wire
July 31, 2000, Monday
Immersion to Acquire Leading Medical Simulation Developer; Merger With HT Medical Systems Reinforces Immersion's Growth In Key Vertical Market
Immersion Corporation, (NASDAQ:IMMR), the pioneering developer of sensory interaction technology, today announced that it has signed a definitive agreement to acquire Gaithersburg, MD-based HT Medical Systems in a pooling transaction currently valued at approximately $42 million. HT Medical Systems designs and manufactures state-of-the-art technology that simulates hands-on medical procedures to create realistic training environments for doctors and other healthcare personnel. Under the terms of the proposed acquisition, HT Medical Systems will become a wholly-owned subsidiary. The transaction is expected to be accounted for as a pooling of interests. It is subject to registration of the Immersion common stock to be issued in the Merger with the Securities and Exchange Commission, approval by more than two-thirds of the stockholders of HT Medical Systems and other customary closing conditions.
The underlying importance of medical simulation is that it allows healthcare providers to practice procedures in an environment where mistakes do not have dire consequences. Medical errors kill between 44,000 and 98,000 Americans per year according to the Institute of Medicine's (IOM) published report, To Err is Human: Building a Safer Health System. HT Medical Systems simulators can help to reduce procedural mistakes by working to fundamentally change the competency assessment and training of healthcare personnel, just as flight simulators revolutionized pilot certification and training decades ago.

The State Journal-Register(Springfield, IL)
July 30, 2000 Sunday
City hospitals to discourage publishing newborns' names
Because of concerns about the possibility of child abductions and lawsuits, Springfield's two maternity hospitals, beginning Tuesday, will stop providing birth announcements to The State Journal-Register.
New parents will be able to put their own birth announcements in the Journal-Register under new procedures established by the newspaper, but officials at St. John's Hospital and Memorial Medical Center will advise them against doing so.
"I don't know if the word I'd use is 'discourage' publication of birth notices, but the word is real close," said Todd Riplinger, director of risk management at Memorial.
"We will recommend that (parents) not do it," said Eileen Streb, supervisor of the Birthing Center at St. John's. She added that St. John's staff members will suggest that new parents not announce new babies by putting balloons, wooden storks or other items in front of their homes.

Federal News Service
July 27, 2000, Thursday
PREPARED TESTIMONY OF CYNTHIA A. BASCETTA ASSOCIATE DIRECTOR VETERANS' AFFAIRS AND MILITARY HEALTH CARE ISSUES HEALTH, EDUCATION, AND HUMAN SERVICES DIVISION UNITED STATES GENERAL ACCOUNTING OFFICE
BEFORE THE HOUSE COMMITTEE ON VETERANS' AFFAIRS SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
Mr. Chairman and Members of the Subcommittee:
We are pleased to be here today to discuss the Department of Veterans Affairs' (VA) effort to improve patient safety, an integral part of VA's overall strategy to improve the quality of health care. VA's quality management strategy is multidimensional and includes programs and internal and external review processes to improve health outcomes, to ensure that providers are competent and well-trained, and to optimize the use of technology to achieve health outcome goals. In this overall system, the role of patient safety activities is to prevent injuries related to care and, when they do occur, identify the causes and countermeasures to prevent them in the future.

Federal Document Clearing House Congressional Testimony
July 27, 2000, Thursday
COMMITTEE: HOUSE VETERANS' AFFAIRS OVERSIGHT AND INVESTIGATIONS
TESTIMONY PATIENT SAFETY AT VA HOSPITAL
Testimony of Cynthia A. Bascetta, Associate Director Veterans' Affairs and Military Health Care Issues Health, Education, and Human Services Division July 27, 2000 Mr. Chairman and Members of the Subcommittee: We are pleased to be here today to discuss the Department of Veterans Affairs (VA) effort to improve patient safety, an integral part of VA s overall strategy to improve the quality of health care. VA s quality management strategy is multidimensional and includes programs and internal and external review processes to improve health outcomes, to ensure that providers are competent and well-trained, and to optimize the use of technology to achieve health outcome goals. In this overall system, the role of patient safety activities is to prevent injuries related to care and, when they do occur, identify the causes and countermeasures to prevent them in the future. My comments today will focus on VA s effort to reduce and prevent patient adverse events in VA health care facilities through its new patient safety initiatives, part of its internal review processes. Adverse events, which occur in both public and private health care facilities, can have tragic consequences, including permanent disability and death. A number of studies have shown that serious injuries sustained from medical care are common and often preventable. A 1997 poll of 1,500 Americans conducted for the National Patient Safety Foundation showed that 42 percent felt that they or a close friend or relative had experienced a preventable adverse event.

The Record (Bergen County, NJ)
July 24, 2000, MONDAY; ALL EDITIONS
ETHICISTS WEIGH DILEMMAS OVER DNA AND AIDS
So it's the night you write your weekly piece on medical ethics, and you have your usual problem: not too little material, but too much. Too many cases in the news, too many tough dilemmas, and too many obvious violations of common-sense ethics. Do you write about the congressional vote on HMOs, which corresponded beautifully with the HMOs campaign contributions? What about the L.A. human-tissue wholesaler that announced it will combine DNA material from different people, in open defiance of industry guidelines? Maybe we can narrow it down. For example, which of these would you write about?

Business Journal-Portland
July 21, 2000
Patient safety statistics sound a wake-up call; Brief Article; Statistical Data Included
Horror stories about medical mix-ups that result in accidental injury and death have been around for decades. But a recent study on patient safety is putting a real scare into the general public. Between 44,000 and 98,000 people in the United States die every year in hospitals alone due to medical errors, according to The Institute of Medicine of the National Academy of Sciences in Washington, D.C.
The IOM released the results of its intensive multiyear study of health-care quality in the United States in November 1999.
"Anybody dying as a result of a medical accident is an alarming thing. We don't accept that serious mistakes are inevitable," said Bruce Rueben, president of the Minnesota Hospital and Healthcare Partnership in St. Paul.

The Columbus Dispatch
July 18, 2000, Tuesday
E-PRESCRIPTIONS SEEN AS LIFESAVER
After 36 years as a pharmacist, David Canowitz has seen his fair share of illegible prescriptions.
Canowitz, who works at the CVS at Broad Street and James Road, said he sometimes has to call physicians to decipher their handwriting so he doesn't dispense the wrong medication. He recalled one such instance in which the call likely kept a customer from serious illness.
"The physician didn't cross an 'x' so it looked like an 'r,' '' Canowitz said. "If I hadn't questioned the patient and called the physician for clarification, I wouldn't have found out that she was pregnant and she may have gotten the wrong medication.''

Albuquerque Journal
July 17, 2000, Monday
Hospitals reviewing computers
* High-tech dispensing systems are aimed at reducing drug errors
A computerized drug-tracking and dispensing system that went awry at the VA Medical Center last month actually is a wave of the future that may show up soon in other local hospitals.
In an attempt to cut down on medication errors, hospitals are looking at systems that use bar-coding and computerized drug orders to double-check what a patient gets at bedside with what the doctor ordered.
Presbyterian Hospital is beginning a four-stage, phase-in of such a system that will be complete sometime in the middle of next year, according to spokeswoman Erika Campos.

Modern Healthcare
July 17, 2000, Monday
Nobody's perfect; IOM report might be flawed, but issue needed to be raised
In this case it may be OK to kill the messenger, but have mercy on the message.
A study in the July 5 issue of the Journal of the American Medical Association supports what some skeptics have quietly believed since the Institute of Medicine released its 1999 bombshell report on medical errors. While the IOM's "To Err is Human" study claimed 44,000 to 98,000 preventable deaths occur each year in U.S. hospitals, cynics among us said those numbers just didn't seem right.

Roll Call
July 17, 2000
What action should be taken to combat deaths due to medical errors? Restore U.S. Confidence in Medicine
Recent publicity over the Institute of Medicine's report on medical errors has ignited disillusionment with our medical system and spurred debate within the medical community, health care regulators and Congress.
With stories of sloppy handwriting or improperly read medical tests resulting in injury or death of a patient, it's not surprising that the American people want action.
The report released last November, "To Err is Human: Building a Safer Health System," not only sparked a national debate about how safe our hospitals and health care settings were for patients, but required the medical community to take a serious look at how to lower the number of medical errors.
The scope of the problem identified in the findings was shocking. Approximately 44,000 to 98,000 hospital deaths a year were attributed to preventable adverse events. Medical errors were estimated to be the eighth- leading cause of death, more than vehicle accidents, breast cancer or deaths resulting from AIDS.

Roll Call
July 17, 2000
Use Common Sense To Reduce Medical Errors
Several months ago, one of my constituents wrote me a letter about her mother, who was being treated for a fracture. A provider at the rehabilitation center where she was staying accidentally gave the mother 16 pills that were intended for her roommate.
While the roommate weighed 180 pounds, this woman weighed only 96 pounds. She died two weeks later.

Scripps Howard News Service
July 17, 2000, Monday
Too many cases, too many tough dilemmas
So it's the night you write your weekly piece on medical ethics, and you have your usual problem: not too little material, but too much. Too many cases in the news; too many tough dilemmas and too many obvious violations of common-sense ethics.
Do you write about the congressional vote on HMOs - which corresponded beautifully with the HMOs' campaign contributions? What about the L.A. human-tissue wholesaler that announced it will combine DNA material from different people, in open defiance of industry guidelines?
Maybe we can narrow it down. For example, which of these would you write about?

U.S. News & World Report
July 17, 2000
Taking the mistakes out of medicine
Someone at Children's Hospitals and Clinics in Minneapolis and St. Paul is blowing the lid off the medical errors that occur there. Dangerous medication mix-ups, misdiagnosed cancers, life-threatening miscommunication between doctors, nurses, and pharmacists--nothing seems to stay secret anymore. The "whistle-blower" is none other than Julie Morath, the hospital system's chief operating officer. If Morath gets her way, she will be joined soon in her error-pointing ways by all of her staff--from the most senior doctors down to even the janitors.
Under Morath's direction, Children's Hospitals and Clinics last year embarked on a daring--many would say futile--experiment: to cut medical errors to zero. "Children's Hospitals is a safe place, but it could be even safer," says Morath, a nurse turned administrator. "We used to compare ourselves with the industry, and we compared well. Then all of a sudden it struck us that maybe the whole industry is not good enough."

Family Practice News
July 15, 2000
Medical Mistakes?
I really don't understand it: Physicians just love to nit-pick the printed word. In fact, we thrive on it. If you publish a study on diabetes, thousands of doctors across the country will tear it apart, mercilessly word by word, line by line, chapter and verse. That's what keeps the science valid.
Yet if you publish a study accusing the medical profession of killing hundreds of thousands of patients, the same physicians will react with a collective yawn. Never--not once--do they ask, "Where's the beef?"

Newsday (New York, NY)
July 14, 2000, Friday ALL EDITIONS
EDITORIAL / HOW MANY PEOPLE DIE FROM MEDICAL ERRORS? FIND OUT
When a prestigious panel of doctors reported last fall that medical errors kill 44,000 to 98,000 hospital patients a year in this country, those numbers were hard to ignore. They were also hard to trust completely.

BestWire
July 10, 2000
MICHIGAN BLUES FOUNDATION AIMS TO HELP PREVENT MEDICAL ERRORS
DETROIT (BestWire) - Blue Cross Blue Shield of Michigan Foundation said it would award $500,000 in grants for Michigan-based doctors, hospitals, academics and others to develop ways to reduce medical errors. This follows the report earlier this year that 44,000 to 98,000 people die nationwide annually from avoidable errors in hospitals. That means more people die from mistakes in hospitals than die from breast cancer, AIDS or motor vehicle accidents, according to the report, "To Err is Human: Building a Safer Health System," produced by the Institute of Medicine's Committee on Quality Health Care in America. The report found preventable medical errors cost the nation as much as $29 billion annually. While some have questioned the report's findings, Ira Strumwasser, executive director of the foundation, said, "Whether it's 3,000, 5,000, or 40,000 people who die, it is too many." He said the foundation saw the report "as an opportunity to develop a grant program to do something about medical errors." In June, a group of doctors, pharmacists, nurses, hospital organizations and others joined Blue Cross Blue Shield of Michigan to form the Michigan Health and Safety Coalition, which is working with the foundation to improve health care in Michigan. The foundation is offering two types of grants. First, grants will be awarded to determine where errors happen in hospitals, what can be done to prevent them, and how the medical community can evaluate programs to prevent errors. Secondly, the foundation will offer "communication grants" to spread the results of the studies to the industry.

Medicine & Health
July 10, 2000
JAMA Writers Debate IOM Error Report.
Three physicians writing in the July 5 issue of the Journal of the American Medical Association fault the recent Institute of Medicine (IOM) medical errors report for its "reliance on studies without controls to make headline claims about huge numbers of preventable deaths." That report said 44,000 to 98,000 Americans die annually in hospitals from medical errors, more than the 43,458 who die in auto accidents. "We believe that the increment in the published death rate due to adverse events [from medical errors] above the baseline death rate could be very small," write Clement J. McDonald, M.D., Michael Weiner, M.D., and Siu Hui, M.D., of the Indiana School of Medicine.

Modern Healthcare
July 10, 2000, Monday
IOM medical error death estimate hit
Reports of 44,000 to 98,000 patient deaths a year from medical errors are greatly exaggerated, according to three researchers at Indiana University Medical School.
Those error estimates grabbed national headlines last November when the Institute of Medicine's report on medical errors was published, but that "hot and shrill" message could lead to bad public policy, researchers Clement McDonald, M.D., Michael Weiner, M.D., and Siu Hui wrote in the July 5 issue of the Journal of the American Medical Association.
In an occasional JAMA feature titled "Controversies," the authors argue that the IOM data "do not support IOM's claim of large numbers of deaths caused by adverse events (preventable or otherwise). Clearly, more study with careful attention to risk levels is needed to determine the true impact of adverse events on death rates among hospitalized patients."

PR NEWSWIRE
July 10, 2000
Blue Cross Blue Shield of Michigan Foundation Announces $ 500,000 Grant Program to Reduce Accidental Injuries in Hospitals

Foundation seeks grant applications from Michigan medical community
DETROIT, July 10 /PRNewswire/ -- The Blue Cross Blue Shield of Michigan Foundation is accepting grant applications from Michigan-based physicians, hospitals, academic institutions and others interested in developing ways to improve patient safety by reducing errors and accidental injuries in hospitals.
The BCBSM Foundation will award $ 500,000 in grants to applicants who will conduct research and disseminate information on best practices that reduce errors and accidental injuries that occur in hospitals.
Patient safety received nationwide attention earlier this year, with the release of a report called "To Err is Human: Building a Safer Health System" by the Institute of Medicine's Committee on Quality in Health Care in America. The report estimated that between 44,000 and 98,000 people die nationwide each year as a result of avoidable errors that occurred in hospitals. The total national cost of preventable medical errors is estimated to be as much as $ 29 billion per year.

PR Newswire
July 10, 2000, Monday
Blue Cross Blue Shield of Michigan Foundation Announces$500,000 Grant Program to Reduce Accidental Injuries in Hospitals;
Foundation seeks grant applications from Michigan medical community
The Blue Cross Blue Shield of Michigan Foundation is accepting grant applications from Michigan-based physicians, hospitals, academic institutions and others interested in developing ways to improve patient safety by reducing errors and accidental injuries in hospitals.
The BCBSM Foundation will award $500,000 in grants to applicants who will conduct research and disseminate information on best practices that reduce errors and accidental injuries that occur in hospitals.
Patient safety received nationwide attention earlier this year, with the release of a report called "To Err is Human: Building a Safer Health System" by the Institute of Medicine's Committee on Quality in Health Care in America. The report estimated that between 44,000 and 98,000 people die nationwide each year as a result of avoidable errors that occurred in hospitals. The total national cost of preventable medical errors is estimated to be as much as $29 billion per year.
In June, a group of physicians, pharmacists, nurses, hospital organizations, health care purchasers, labor and health plans along with Blue Cross Blue Shield of Michigan formed the Michigan Health and Safety Coalition. The coalition is the first group of its kind in the state that brings together a diverse group of individuals and organizations committed to improving the safety of patient care.
"The Michigan Health and Safety Coalition is working in Michigan to be a leader in the effort to enhance patient safety," said Marianne Udow, Blues senior vice president, Health Care Products and Provider Services.

Dayton Daily News
July 6, 2000, Thursday,
RESEARCHERS SAY ERRORS NOT SO NUMEROUS
CHICAGO - A 1999 report that said medical mistakes kill as many as 98,000 hospitalized Americans each year used flawed methodology and is greatly exaggerated, researchers reported Wednesday.
Scientists at the Indiana University School of Medicine said they suspect the death toll from errors is in fact very small and called parts of the November report from the Institute of Medicine ''hot and shrill.''

The Herald-Sun (Durham, N.C.)
July 6, 2000, Thursday
News in brief

Investor's Business Daily
July 6, 2000
Claims Of Deaths Via Medical Errors Wildly Overblown
A 1999 report that said medical mistakes kill as many as 98,000 hospitalized Americans each year used flawed methodology and is greatly exaggerated, researchers reported Wednesday. Scientists at the Indiana University School of Medicine said they suspect the death toll from errors is in fact very small, and called the parts of the November report from the Institute of Medicine "hot and shrill." The report, the researchers said, never established that medical errors caused the deaths and failed to eliminate other risks for sick patients before drawing conclusions. "The available data do not support IOM's claim of large numbers of deaths caused by adverse events, (preventable or otherwise)," wrote Clement J. McDonald and two Indiana colleagues in the Journal of the American Medical Association. In a rebuttal article, Dr. Lucian L. Leape of the Harvard School of Public Health argued that the IOM report is accurate. Leape co-authored the report and conducted some of the research on which it is based. The groundbreaking report said medical errors kill from 44,000 to 98,000 hospitalized Americans each year and called for major changes in the nation's health care system to protect patients. The report said the problem isn't recklessness by doctors or nurses as much as it is the result of flaws in the way hospitals, clinics and pharmacies operate. After the report, President Clinton said hospitals should agree to routine reporting of serious and deadly mistakes. In Wednesday's rebuttal, Leape said his report actually may have underestimated the extent of the problem because many errors are never recorded in medical records.

Medical Industry Today
July 6, 2000, Thursday
Experts Clash over Medical Errors Report
The number of deaths attributed to medical errors in a highly publicized 1999 report was exaggerated, according to an opinion article published this week in the Journal of the American Medical Association (JAMA). But in an opposing article in the same issue, a scientist wrote that, if anything, the findings of the 1999 report underestimated the true extent of mistakes.
According to the report issued last year by the Institute of Medicine, between 44,000 and 98,000 people annually die as a result of medical errors. The institute stated that more people die from medical mistakes each year than from highway accidents, breast cancer or AIDS, as reported previously by Medical Industry Today.

NBC News Transcripts
SHOW: TODAY (7:00 AM ET)
July 6, 2000, Thursday
DR. CLEMENT MCDONALD AND DR. LUCIAN LEAPE DISCUSS REPORT ON MEDICAL MISTAKES MADE IN HOSPITALS
KATIE COURIC, co-host:
On CLOSE UP this morning, controversy over medical mistakes. Last year a major report by the Institute of Medicine claimed that up to 98,000 people die every year due to medical mistakes made in hospitals. But now those numbers are being challenged. A team of doctors from Indiana University published an article in the Journal of the American Medical Association calling these figures greatly exaggerated. Dr. Clement McDonald is the author of this latest article.
Dr. McDonald, good morning.
Dr. CLEMENT McDONALD (Indiana University School of Medicine): Good morning.
COURIC: You say this study is flawed, why?

Newsday (New York, NY)
July 6, 2000, Thursday NASSAU AND SUFFOLK EDITION
DISPUTE OVER STUDY ON MEDICAL ERRORS
Last November, a committee of scientists presented the public with shocking data: that medical errors kill tens of thousands of people-as many as 98,000-in the United States every year.
Now Indiana scientists, writing in yesterday's Journal of the American Medical Association, say those numbers were exaggerated.
The high estimates, the scientists write, assumed that every time someone died and a medical error had occurred the error was the cause of death. In fact, they argue, many of the deaths may have had nothing to do with the errors.

TULSA WORLD
July 6, 2000
Which is it? Conflicting reports confuse many
Most Americans were shocked and sickened by the findings of a 1999 report that indicated that as many as 98,000 fellow citizens die each year because of mistakes made in hospitals. That could be any of us, we all thought to ourselves.
Now along comes another report which suggests the earlier report was seriously flawed, that nowhere near that many Americans die as a result of hospital mistakes.

The Deseret News (Salt Lake City, UT)
July 5, 2000, Wednesday
SECTION: WIRE; Pg. A03
How deadly are medical errors?
CHICAGO -- A 1999 report that said medical mistakes kill as many as 98,000 hospitalized Americans each year used flawed methodology and is greatly exaggerated, researchers reported Wednesday.
Scientists at the Indiana University School of Medicine said they suspect the death toll from errors is in fact very small and called the parts of the report from the Institute of Medicine "hot and shrill."
The report, the researchers said, never established that medical errors caused the deaths and failed to eliminate other risks for sick patients before drawing conclusions.

The Florida Times-Union (Jacksonville, FL)
July 5, 2000 Wednesday, City Edition
AMA journal asserts count exaggerated medical errors Report started call for more oversight
An alarming and highly influential 1999 report which concluded that as many as 98,000 Americans die every year from preventable medical errors is itself being criticized as erroneous by some experts.
The debate, which has been simmering for months, attains prominence today with the publication of dueling opinion articles in the Journal of the American Medical Association. The articles highlight the difficulty of accurately tallying medical errors and underscore the extreme sensitivity of the topic in today's litigious medico-legal environment.

Los Angeles Times

July 5, 2000, Wednesday, Home Edition
CALIFORNIA AND THE WEST;
REOPENING DEBATE ON MEDICAL ERRORS;
HEALTH: TWO ARTICLES REVISIT A SHOCKING CLAIM MADE LAST YEAR ABOUT PATIENTS' DEATHS. ONE CAMP SUSPECTS EXAGGERATION; THE OTHER THINKS FIGURES ARE TOO LOW.
Last November, a committee of scientists presented the public with shocking data: that medical errors kill tens of thousands of people--as many as 98,000--in the U.S. every year.
Now a group of Indiana scientists, writing in today's issue of the Journal of the American Medical Assn., says those numbers were highly exaggerated.
The high estimates, they write, assumed that, every time someone died and a medical error had occurred, the error was the cause of death. In fact, they argue, many deaths may have had nothing to do with the errors.

Milwaukee Journal Sentinel
July 5, 2000 Wednesday FINAL EDITION
Scientists rebut finding on medical errors;
Indiana group says report exaggerated death toll caused by such mistakes
Last November, a committee of scientists presented the public with shocking data: that medical errors kill tens of thousands of people -- as many as 98,000 -- in the United States every year.
Now a group of Indiana scientists, writing in today's issue of the Journal of the American Medical Association, says those numbers were highly exaggerated.
The high estimates, the scientists write, assumed that every time someone died and a medical error had occurred, the error was the cause of death. In fact, they argue, many of the deaths may have had nothing to do with the errors.

United Press International
July 5, 2000, Wednesday
Experts split on hospital dangers
The chances of dying in hospital because of a medical accident are "very small," or higher than being killed in a car crash depending on who you ask, according research published today.
The in-print duel in Wednesday's issue of the Journal of the American Medical Association is over last year's Institute of Medicine report. The report concluded that between 44,000 and 98,000 people die each year in United States hospitals because of medical errors.
Even using the low estimate that makes hospital goofs a bigger cause of death than highway accidents, breast cancer and AIDS. Dr. Clement J. McDonald told UPI, "the numbers they used to compute the number of deaths is nothing you could use to decide" the extent of the problem.

USA TODAY
July 5, 2000, Wednesday, FINAL EDITION
Medical errors not so deadly? 'Shrill' estimate not supported by data, doctors say
A headline-grabbing report that estimated 44,000 to 98,000 people
die each year because of medical errors may have exaggerated the
numbers, a review says.
"Where are the bodies? We just don't see that many," says Clement
McDonald of the Indiana University School of Medicine in Indianapolis.
An analysis he and colleagues wrote for today's Journal of
the American Medical Association accuses the report of sending
a misleading, "hot and shrill" message about medical errors.

The Washington Post
July 5, 2000, Wednesday, Final Edition
Report on Medical Errors Called Erroneous; Fueling Debate, Researchers Challenge Data Indicating Thousands Die Because of Mistakes
An alarming and highly influential 1999 report which concluded that as many as 98,000 Americans die every year from preventable medical errors is itself being criticized as erroneous by some experts.
The debate, which has been simmering for months, attains prominence today with the publication of dueling opinion articles in the prestigious Journal of the American Medical Association. The articles highlight the difficulty of accurately tallying medical errors and underscore the extreme sensitivity of the topic in today's litigious medico-legal environment.
In one of the articles, three critics assert that the medical error figures used in last year's Institute of Medicine (IOM) report were greatly exaggerated and that the subsequent flurry of efforts to increase oversight of medical professionals was "premature."

Medical Marketing & Media
July 1, 2000
INDUSTRY FACES THE DRUG SAFETY ISSUE; Statistical Data Included
PhRMA scientific staff leads a Task Force to respond to public and political concerns
EXECUTIVE SUMMARY:
Efforts at improving drug safety is an ongoing activity at PhRMA. Now the sharper focus on medical errors resulting from the report by the Institute of Medicine has prompted formation of a ten-person PhRMA Task Force. It will respond to public concern by recommending further steps the industry may take to reduce medication errors.
The safety of pharmaceuticals has been and will always he a fundamental concern of the prescription drug industry and of all groups associated with drugs. But now there is a particularly pointed focus in the public policy arena on the issue of safety, as a result of attention brought by the November 1999 Institute of Medicine (IOM) report on medical errors.
Nursing Management
July 1, 2000
Providing a safe environment in the new millennium; Brief Article
While traveling in London last year, I visited the Florence Nightingale museum. Besides gaining a deeper appreciation of her many contributions to nursing, I learned that she was well ahead of her time regarding patient safety in hospitals.
Of course, when Nightingale founded professional nursing in the 19th century, people often viewed hospitals as a place of last resort. In the Crimean War, the Scutari Hospital didn't have beds, clean laundry, food, water, or operating tables until she arrived. One of her strongest acts was to create an effective hospital environment for patients and staff.

Star Tribune (Minneapolis, MN)
June 29, 2000, Thursday, Metro Edition
Malpractice suit filed against Fairview
A lawsuit was filed Wednesday against Fairview Health Services of Minneapolis alleging malpractice in a case of a woman who lapsed into a coma while she was recovering from elective hysterectomy surgery.
The suit, filed in Hennepin County District Court, alleges that Fairview-University Medical Center staff failed to properly monitor Sharon Williams, 42, after she came out of surgery in April.
Williams went into respiratory arrest after receiving morphine for pain, but hospital staff were not alerted to her distress because alarms on monitoring equipment had been disabled, according to the complaint.

The Providence Journal-Bulletin
June 26, 2000, Monday, Metro EDITION
State looks to curb medical mistakes
As part of the effort to address errors, the new state budget allocates $300,000 to hire a team of consultants for one year.
* *
Last fall, the Institute of Medicine identified a leading cause of death that caught many people by surprise.
Some 44,000 to 98,000 Americans die each year, the report said, because their medical caregivers make mistakes. Most of those errors result not from incompetence, but from ordinary slip-ups such as misreading a doctor's handwriting or consulting the wrong patient's file.

Minneapolis-St. Paul CityBusiness
June 23, 2000
Health care checks up patient safety.
Alarming statistics on accidents sound a wake-up call
Horror stories about medical mix-ups that result in accidental injury and death have been around for decades. But a recent study on patient safety is putting a real scare into the general public.
Between 44,000 and 98,000 people in the United States die every year in hospitals alone due to medical errors, according to The Institute of Medicine (IOM) of the National Academy of Sciences in Washington, D.C. The IOM released the results of its intensive multiyear study of health-care quality in the United States in November 1999.
"Anybody dying as a result of a medical accident is an alarming thing. We don't accept that serious mistakes are inevitable," says Bruce Rueben, president of the Minnesota Hospital and Healthcare Partnership (MHHP) in St. Paul. "Clearly those numbers indicate that we have a lot of work to do."

Plastic Surgical Nursing
June 22, 2000
To Err -- Human Condition?
A flurry of headlines in the popular press accompanied by thunderbolts of commentary in the media are focusing on the "appalling" incidence of medical errors. Presidential candidates, moms and dads, welfare recipients -- patients from all walks of life are demanding accountability from the health care industry. Their prevailing attitude is "zero tolerance" for error. In plain English, they want assurance that the cure isn't worse than the problem(s) being treated. If to err is human, then who will provide future medical care?
In my community, patients are still turning to local plastic surgeons and their staff for cosmetic and reconstructive procedures. Fortunately, a variety of resources are available to plastic surgeons and their office/surgery center managers that can help control medical errors. This column focuses on what is being done within the surgical specialty to prevent human and mechanical error.

Plastic Surgical Nursing
June 22, 2000
Study Documents Nurses' Assessment of the Value of Certification.
The Plastic Surgical Nursing Certification Board (PSNCB) is continually striving to promote certification among our plastic surgical nursing colleagues. On a more global scale, the PSNCB actively participates and collaborates with other specialty nursing certifying bodies through the National Specialty Nursing Certifying Organization (NSNCO) in addressing issues related to certification, licensure, education, and research. In 1999, the PSNCB joined the Nurse Credentialing Research Coalition (NCRC) and participated in a research project through the American Nurses Credentialing Center (ANCC), which addressed nurses and certification. All of our certified nurses received a questionnaire in the mail. This initial phase of the research yielded some extremely interesting facts. The following is a reprint of the press release from the ANCC that outlines the study and gives some amazing findings. Certified nurses everywhere will find this extremely interesting and important to their careers.
Survey Links Certification with Improved Health Care

Pittsburgh Post-Gazette
June 20, 2000, Tuesday, SOONER EDITION
AT THE HOSPITAL, ASK QUESTIONS;
IT'S THE INFORMED PATIENT'S WAY TO AVOID ERRORS AND INFECTION
Name the most dangerous places in daily life, where every minute brings a real risk of accidental injury or death. Airplanes? Busy highways? Deserted streets at night? Travel in remote parts of the world?
Most people wouldn't dream of including hospitals. Yet studies have shown that they are among the most dangerous places on Earth. They also are well-populated places. About 33.6 million people are admitted to hospitals in the United States each year.

PR NEWSWIRE
June 20, 2000
Technologies to Reduce Medical Errors Will Be Highlighted at June 22 Event

A June 22 Medical Technology Breakfast Forum on Capitol Hill will discuss how innovative medical technologies can be used in the fight to reduce medical errors, the Health Industry Manufacturers Association (HIMA) announced today. The event will begin at 8:30 a.m.
An Institute of Medicine report released in November 1999 estimated that between 44,000 and 98,000 people Americans die each year due to medical errors. While many lawmakers and government agencies scramble to find solutions to this problem, leaders of the medical technology community have a strong historical commitment to developing new technologies that combat this problem through: * Innovative device designs * Training for health care professionals who use these tools, and * Voluntary, cooperative efforts between technology companies and the clinical community to advance patient safety
The breakfast will allow members of the media to hear first-hand from physicians and medical technology experts. It also will include demonstrations of several new technologies, including: * The BD Rx and Dx Systems are designed to improve specimen management and medication administration, allowing clinicians to access important information about dosage and avoid potential drug interactions. * The 3M Care Innovation is a computer-based patient record system that translates information into a universal language and alerts clinicians to potential medication and treatment errors. * STERIS SYSTEM 1 is a complete system for just-in-time sterile processing at or near the site of patient care, enabling health care professionals to reduce infections in the clinical setting. WHO: Rep. Karen Thurman (D-FL) Rep. Jim Ramstad (R-MN) Pamela G. Bailey, HIMA president Dr. J.S. Gravenstein, emeritus graduate research professor, University of Florida WHAT: Medical Technology Breakfast Forum WHEN: Thursday, June 22, 2000 at 8:30-10 a.m. WHERE: Room B-369, Rayburn House Office Building

The Houston Chronicle
June 17, 2000, Saturday 3 STAR EDITION
Forum addresses health care errors ;
Group examines reporting efforts
Ten years ago, St. Louis surgeon John Hirsch lost a patient who received the wrong medication by mistake. Pointing fingers eventually placed blame on a nurse, who was promptly fired by administrators.
Hirsch was disturbed by the way the case was handled because it did nothing to prevent future errors.

DENVER ROCKY MOUNTAIN NEWS
June 13, 2000, Tuesday
LETTERS PAGE

Federal News Service

June 13, 2000, Tuesday
HEARING OF THE CIVIL SERVICE SUBCOMMITTEE OF THE HOUSE GOVERNMENT REFORM COMMITTEE
SUBJECT: THE FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM
CHAIRED BY: REPRESENTATIVE JOSEPH SCARBOROUGH (R-FL)
LOCATION: 2154 RAYBURN HOUSE OFFICE BUILDING, WASHINGTON, D.C.
TIME: 10:00 AM. EDT DATE: TUESDAY, JUNE 13, 2000
REP. JOE SCARBOROUGH (R-FL): I want to call this hearing to order, and I want to welcome everybody and thank you for your interest in the Federal Employees Health Benefits Program. I believe one of the most important duties for this subcommittee is to oversee this critical program. Approximately 9 million federal employees, retirees and their families all rely on the FEHBP for health care coverage.
The program has been widely cited as a model employer-sponsored health benefits program and even as a model for reforming Medicare. The key to its success has been affordable premiums and consumer choices that result from hundreds of health benefit plans competing for the business of individual employees and retirees. And although it's an excellent program, the FEHBP like all health care plans today faces some serious, serious challenges.
Premiums have risen dramatically over the past three years, and another substantial increase seems imminent for 2001. The purpose of today's hearing is to examine the OPM's administration of this critically important program. We're going to examine the policies established by OPM's call letter for 2001 as well as well as several ongoing matters.

PR NEWSWIRE
June 8, 2000
System Overhauls are Required to Make Medical Care Safer For Patients, Experts Say

Academic Medicine and Managed Care Forum Speakers Share Strategies to Avoid
Preventable Medical Errors
WASHINGTON, June 8 /PRNewswire/ -- Patient safety must be a national priority, but major systems changes will be needed to reverse the results of recent studies on medical errors, according to one of the nation's leading health policy experts.
Dr. Lucian L. Leape, Adjunct Professor of Health Policy at the Harvard School of Public Health, addressed the problem of medical errors this morning in a keynote address before the Academic Medicine and Managed Care Forum (Forum), an alliance of 50 academic medical centers and teaching hospitals, pharmaceutical companies and Aetna U.S. Healthcare. The meeting was convened at the Monarch Hotel in Washington, D.C.
A recent Institute of Medicine report raised serious concerns about the damage caused by avoidable medical errors, drew significant attention from the media and health care consumers, and resulted in a Presidential Order to attack the problem. According to the IOM report, medical errors account for between 44,000 and 98,000 deaths each year in the United States.

PR Newswire
June 8, 2000, Thursday
System Overhauls are Required to Make Medical Care Safer For Patients, Experts Say;
Academic Medicine and Managed Care Forum Speakers Share Strategies to Avoid Preventable Medical Errors
Patient safety must be a national priority, but major systems changes will be needed to reverse the results of recent studies on medical errors, according to one of the nation's leading health policy experts.
Dr. Lucian L. Leape, Adjunct Professor of Health Policy at the Harvard School of Public Health, addressed the problem of medical errors this morning in a keynote address before the Academic Medicine and Managed Care Forum (Forum), an alliance of 50 academic medical centers and teaching hospitals, pharmaceutical companies and Aetna U.S. Healthcare. The meeting was convened at the Monarch Hotel in Washington, D.C.
A recent Institute of Medicine report raised serious concerns about the damage caused by avoidable medical errors, drew significant attention from the media and health care consumers, and resulted in a Presidential Order to attack the problem. According to the IOM report, medical errors account for between 44,000 and 98,000 deaths each year in the United States.
In a speech examining the myths and realities concerning the safety of our health care system, Dr. Leape said timely, accurate reporting of medical errors is essential if systems improvements are to be made. "You can't fix systems you don't know are broken," he said. But all reporting is essentially voluntary, he noted, and people involved in the health care system need to stop looking for people to blame and start working on preventing errors.
Dr. Leape was one of several experts who discussed the issue of reducing medical errors at this morning's meetings.

The Salt Lake Tribune
June 8, 2000, Thursday
Not All Medical Errors Result From Negligence
To many laypeople, "medical error" implies a goof, screwup or blunder caused by incompetence or negligence.
But for an Institute of Medicine (IOM) committee that estimated 44,000 to 98,000 Americans are killed each year by medical errors, the phrase had a broader meaning: a preventable injury caused by medical care.
In a report last November, the 19-member committee said the majority of medical errors "do not result from individual recklessness, but from basic flaws in the way the health system is organized." It cited as examples illegible writing on medical records, doctors failing to share information on patients, and difficulty keeping up with the latest knowledge.
The Salt Lake Tribune
June 8, 2000, Thursday
Utah Had Key Role In Medical Error Study
When the Institute of Medicine estimated last November that medical mistakes kill 44,000 to 98,000 hospitalized Americans each year, few people realized the estimate drew heavily on a landmark study of Utah and Colorado hospitals.
In recent months, key parts of that Harvard University study were published in medical journals. The findings suggest that out of some 200,000 Utah residents hospitalized during a given year, about 5,600 are injured by their medical care rather than by their disease, and roughly 370 of the injured die.
Despite those grim statistics, researchers found the death rate from medical injuries in Utah and Colorado hospitals was much lower than in an earlier Harvard study of such deaths in New York state.
For that reason, the Utah-Colorado study was the basis for the Institute of Medicine's (IOM) estimate of at least 44,000 deaths annually due to "medical errors," while the New York research led to the estimate of 98,000 deaths per year.

PR NEWSWIRE
June 7, 2000
Michigan Health and Safety Coalition Formed to Improve Health Care Quality and Patient Safety

DETROIT, June 7 /PRNewswire/ -- A group of physician, pharmacists, nurses, and hospital organizations, health care purchasers, labor and health plans have formed the Michigan Health and Safety Coalition, the first group of its kind in the state that brings together diverse groups committed to improving the safety of patient care.
The coalition is comprised of representatives from Blue Cross Blue Shield of Michigan, International Union-UAW, Michigan Association of Health Plans, Michigan Health & Hospital Association, Michigan Nurses Association, Michigan State Medical Society, Michigan Osteopathic Association and Michigan Pharmacists Association, the Michigan Peer Review Organization, as well as representatives from several employer groups -- General Motors Corp., Michigan Education Special Services Association and the Michigan Public School Employees Retirement System.
The issue of patient safety drew nationwide attention earlier this year with the release of a report called "To Err is Human: Building a Safer Health System" by the Institute of Medicine's Committee on Quality in Health Care in America.

PR Newswire
June 7, 2000, Wednesday
Michigan Health and Safety Coalition Formed to Improve Health Care Quality and Patient Safety
A group of physician, pharmacists, nurses, and hospital organizations, health care purchasers, labor and health plans have formed the Michigan Health and Safety Coalition, the first group of its kind in the state that brings together diverse groups committed to improving the safety of patient care.
The coalition is comprised of representatives from Blue Cross Blue Shield of Michigan, International Union-UAW, Michigan Association of Health Plans, Michigan Health & Hospital Association, Michigan Nurses Association, Michigan State Medical Society, Michigan Osteopathic Association and Michigan Pharmacists Association, the Michigan Peer Review Organization, as well as representatives from several employer groups -- General Motors Corp., Michigan Education Special Services Association and the Michigan Public School Employees Retirement System.
The issue of patient safety drew nationwide attention earlier this year with the release of a report called "To Err is Human: Building a Safer Health System" by the Institute of Medicine's Committee on Quality in Health Care in America.
The Institute of Medicine report estimated that 44,000 to 98,000 Americans die each year as a result of medical errors, based on two studies that looked at outcomes for a combined 60,000 hospitalized patients in three states. The report went on to say that errors are costly, generating total national costs between $17 billion and $29 billion.
The report said medical errors occur because of system failures and preventing errors means designing safer systems of care. The authors defined a medical error as the failure of a planned medical action to be completed as intended or the use of a wrong medical plan to achieve an aim.

St. Louis Post-Dispatch
June 7, 2000, Wednesday, FIVE STAR LIFT EDITION
SPACE AGE PATIENT PROTECTION
MEDICAL MISTAKES
PREVENTING medical errors isn't rocket science. But the Veterans Administration is about to get help accomplishing that worthy goal from the nation's space agency. Last week, the VA signed a three-year, $ 8.2 million contract with NASA to develop a system in which errors can be confidentially reported and, it is hoped, corrected. It will be modeled on a well-regarded NASA-run airline safety program.

Business Wire
June 5, 2000, Monday
Two Upstate New York Area Hospitals Purchase AUTROS Medication Management System; Objective Is Greater Patient Medication Safety
Faxton-St. Luke's Healthcare in Utica, NY and St. Peter's Hospital in Albany, NY have purchased AUTROS Point-of-Care Medication Management Systems for real-time monitoring of medication administration to patients.
Ted Hahn, St. Peter's director of pharmacy, said, "Providing our caregivers with the AUTROS technology offers us the most technologically advanced tool available for delivering the highest level of medication safety to our patients." By providing the real-time monitoring system, Hahn said, the hospital could better control costs, decrease paperwork, improve record keeping and supply management.

Copley News Service
June 2, 2000, Friday
VA borrows a laudable safety plan
When nothing you've tried seems to solve a problem, often it's best to get help from folks who have been there and done that. That's what the Department of Veterans Affairs concluded, so it went to a cousin in the federal agency family: the National Aeronautics and Space Administration.
NASA has long had a much-admired program that allows pilots and others to report near-collisions of aircraft and other potential safety problems without fear of retribution. The ability to do such things would be important in any medical setting. At the VA, with 172 hospitals and many lives in the balance, it takes on added significance.

Omaha World-Herald
June 2, 2000, Friday SUNRISE EDITION
VA Borrows a Laudable Safety Plan
When nothing you've tried seems to solve a problem, often it's best to get help from folks who have been there and done that. That's what the Department of Veterans Affairs concluded, so it went to a cousin in the federal agency family: the National Aeronautics and Space Administration. NASA has long had a much-admired program that allows pilots and others to report near-collisions of aircraft and other potential safety problems without fear of retribution. The ability to do such things would be important in any medical setting. At the VA, with 172 hospitals and many lives in the balance, it takes on added significance. A report last year from the widely respected Institute of Medicine concluded that medical mistakes in hospitals kill 44,000 to 98,000 Americans a year. Different studies have speculated on different totals, but all have been in the tens of thousands. The VA concluded that such numbers could be lowered more easily if it weren't for commonly expressed concerns from health workers that if they disclose errors they might be sued or fired. And, as Dr. Thomas Garthwaite, the VA's acting undersecretary for health, told The Associated Press, "If you don't know about it, you can't fix it." Thus, the NASA transplant. Under new procedures, all VA health workers may report medical mistakes they cause or observe. No doctor or nurse would be held personally at fault. After questioning the individual for details, investigators will delete all identifying information from their database, then analyze what went wrong, with an eye to preventing recurrences.

Family Practice News
June 1, 2000
Medical Errors Getting Attention in Congress; Statistical Data Included; Brief Article
WASHINGTON -- Legislation aimed at reducing the number of medical errors is expected to be introduced soon, "and it's likely to pass," Sen. Bill Frist (R-Tenn.) said at a press briefing on medical errors sponsored by the Alliance for Health Reform.
One bill was introduced in February by Sen. Arlen Specter (R-Pa.). Another bill is expected to be introduced in the next several months, Sen. Frist, a former cardiac surgeon, said at the briefing, also sponsored by the Commonwealth Fund.

Health Management Technology
June, 2000
Real-time Notification of Medication Errors
The recent Institute of Medicine report that medical errors kill between 44,000 and 98,000 hospitalized Americans annually drew a glaring public spotlight to a problem that the industry has been grappling with for years.
The annual cost of drug-induced morbidity in the United States is estimated at $ 7 billion, and drug-induced toxicity occurs in 3 percent to 5 percent of all hospital admissions. While there is bound to be error in any human endeavor, the frequency of medication errors is greater than it needs to be.
One key to reducing the morbidity and costs associated with medication errors is providing real-time decision support and timely notification of potentially inappropriate medication orders to the healthcare providers responsible for patient care.

Newsday (New York, NY)
June 1, 2000, Thursday NASSAU AND SUFFOLK EDITION
BRIEFS

Nursing Management
June 1, 2000
Medical Errors, Airplanes, and Information Technology.
Late last year, the Institute of Medicine (IOM) confirmed what many of us in health care already knew: We're paying a high cost for medication errors in lives and dollars. The solution? Not better punishment for caregivers, but better information systems.
To err is human
The numbers are now familiar. Medical errors in U.S. hospitals kill between 44,000 and 98,000 people each year. Medication errors alone kill more than 7,000.

The Bulletin's Frontrunner
May 31, 2000
VA To Use NASA To Report Medical Errors.
AP (5/31) reported, "In a groundbreaking program, the nation's 172 veterans hospitals hired NASA today to do for medical safety what it does for aviation safety: set up a system where errors can be reported without fear of penalty and use the information to make everyone safer. A report by the Institute of Medicine concluded last year that medical mistakes killed 44,000 to 98,000 hospitalized Americans a year.

Chattanooga Times / Chattanooga Free Press
May 31, 2000, Wednesday
VA Hospitals Hire NASA To Aid in Medical Safety
WASHINGTON -- In a groundbreaking program, the nation's veterans hospitals hired NASA on Tuesday to do for medical safety what it does for airline safety: Set up a system where errors can be reported without fear of penalty and use the information to make everyone safer.
A NASA-run program that lets pilots report near misses is widely considered so successful at improving aviation safety that the Department of Veterans Affairs wants a similar program to combat medical mistakes. It would let doctors and nurses report problems that, if fixed, could improve care in the VA's 172 hospitals.

Chicago Daily Herald
May 31, 2000, Wednesday, Cook,Lake
Unique way to reduce mistakes in medicine
A most unsettling public health report, issued last year by the Institute of Medicine, found that medical errors annually kill 44,000 to 98,000 Americans. Since then, President Clinton has called for a system of mandatory reporting of fatal medical errors that would encourage compliance without inviting a flurry of liability lawsuits.

Dayton Daily News
May 31, 2000, Wednesday,
VA RETAINS NASA TO CUT ERROR RATE
WASHINGTON - In a groundbreaking program, the nation's veterans hospitals hired NASA on Tuesday to do for medical safety what it does for airline safety: Set up a system where errors can be reported without fear of penalty and use the information to make everyone safer.
A NASA-run program that lets pilots report near misses is widely considered so successful at improving aviation safety that the Department of Veterans Affairs wants a similar program to combat medical mistakes. It would let doctors and nurses report problems that, if fixed, could improve care in the VA's 172 hospitals.

The Florida Times-Union (Jacksonville, FL)
May 31, 2000 Wednesday, State Edition
VA hires NASA to cure safety mistakes
WASHINGTON -- In a groundbreaking program, the nation's veterans hospitals hired NASA yesterday to do for medical safety what it does for airline safety: set up a system where errors can be reported without fear of penalty and use the information to make everyone safer.
A NASA-run program that lets pilots report near misses is widely considered so successful at improving aviation safety that the Department of Veterans Affairs wants a similar program to combat medical mistakes.

Investor's Business Daily
May 31, 2000
Trends . Top players giving up CEO title to focus more on global strategy Starbucks, Microsoft, Infospace, and Amazon.com all have had major changes in leaders over the past year. Investors have reacted favorably to the creation of two-person teams. The team members say their common goals and trust turn into opportunities for growth. The first step in shuffling duties for a CEO is letting go, said UCLA professor Samuel Culbert. Ease of online shopping offset by late or missed deliveries About 2.1 billion packages will be shipped to U.S. homes between now and 2003, with 12% not on time, said consultant Forrester Research. To remedy this, FedEx is delivering on Saturdays and evenings. Mail Boxes Etc. accepts deliveries for $ 20 a month. Also, consumers can pay $ 30 to ensure a specific delivery time. V.A. to imitate aviation program in quest for better patient safety The nation's veterans hospitals hired NASA to do for medical safety what it does for airlines: Set up a system where errors can be reported without fear of penalty and use the information to make everyone safer. The Institute of Medicine last year found medical mistakes kill 44,000 to 98,000 Americans a year. Some 29% of brides-to-be said the Web is their top source of data for wedding plans, said a Greenfield Online survey. & Innovation Stem cells grown in laboratory excite Parkinson's researchers U.S. researchers generated new neurons using embryonic stem cells from mice, said the journal Nature Biotechnology.

The New York Times

May 31, 2000, Wednesday, Late Edition - Final
V.A. Plans No-Penalty Medical Error Reporting
In a groundbreaking program, the nation's 172 veterans hospitals hired NASA today to do for medical safety what it does for aviation safety: set up a system where errors can be reported without fear of penalty and use the information to make everyone safer.
A report by the Institute of Medicine concluded last year that medical mistakes killed 44,000 to 98,000 hospitalized Americans a year.

The Record (Bergen County, NJ)
May 31, 2000, WEDNESDAY; ALL EDITIONS
NASA TO LAUNCH MEDICAL ERROR REPORTING SYSTEM FOR VA OFFICIALS HOPE FOR IMPROVEMENT IN CARE
In a groundbreaking program, the nation's veterans hospitals hired NASA on Tuesday to do for medical safety what it does for airline safety: set up a system in which errors can be reported without fear of penalty and use the information to make everyone safer.
A NASA-run program that lets pilots report near misses is widely considered so successful at improving aviation safety that the Department of Veterans Affairs wants a similar program to combat medical mistakes. It would let doctors and nurses report problems that, if fixed, could improve care in the VA's 172 hospitals. A stunning report by the prestigious Institute of Medicine last year concluded that medical mistakes kill 44,000 to 98,000 hospitalized Americans a year.

St. Petersburg Times
May 31, 2000, Wednesday, 0 South Pinellas Edition
NASA to help VA hospitals prevent errors
In a groundbreaking program, the nation's veterans hospitals hired NASA on Tuesday to do for medical safety what it does for airline safety: set up a system where errors can be reported without fear of penalty and use the information to make everyone safer.
A NASA-run program that lets pilots report near misses is widely considered so successful at improving aviation safety that the Department of Veterans Affairs wants a similar program to combat medical mistakes. It would let doctors and nurses report problems that, if fixed, could improve care in the VA's 172 hospitals.

St. Louis Post-Dispatch
May 31, 2000, Wednesday, FIVE STAR LIFT EDITION
VA HOSPITALS SET UP SYSTEM FOR REPORTING ERRORS ANONYMOUSLY;
NASA IS HIRED TO RUN PROGRAM SIMILAR TO ONE IT USES FOR AIR SAFETY
The nation's veterans hospitals hired NASA on Tuesday to do for medical safety what it does for airline safety: set up a system where errors can be reported without fear of penalty and use the information to make everyone safer.
A program run by the National Aeronautics and Space Administration that lets pilots report near misses is widely considered to be so successful at improving aviation safety that the Department of Veterans Affairs wants a similar program to combat medical mistakes. It would let doctors and nurses report problems that, if solved, could improve care in the VA's 172 hospitals.

The Washington Post
May 31, 2000, Wednesday, Final Edition
NASA to Hunt Errors In 172 VA Hospitals; Reporting System Mirrors Aviation's
In a groundbreaking program, the nation's veterans hospitals hired NASA yesterday to do for medical safety what it does for airline safety: set up a system where errors can be reported without fear of penalty and use the information to make everyone safer.
A NASA-run program that lets pilots report near misses is considered so successful at improving aviation safety that the Department of Veterans Affairs wants a similar program to combat medical mistakes. It would let doctors and nurses report problems that, if fixed, could improve care in the VA's 172 hospitals.

Modern Healthcare
May 29, 2000, Monday
Transformation in small doses
At a time when consumers shop for cars, financial investments and home mortgages online, electronic prescription for drugs might not seem like much of a stretch.
But a stretch it is. Although much of e-commerce is growing out of its infancy, the computerized prescription is still the baby of the family.
A number of companies, from dot-com start-ups to established types such as Merck-Medco Managed Care, are making forays into the market. But the day is still far away when it's common for a doctor to compose a prescription on a computer screen and transmit it to a pharmacy.

The Herald-Sun (Durham, N.C.)
May 28, 2000, Sunday
'Witch Doctor' gets to root of bad medicine
Hospitals and doctors are just part of the everyday scenery for those of us who live in the City of Medicine. But that is not true everywhere.
There are still isolated areas where the towns are small and the nearest hospital is more than an hour's drive away. There may or may not be clinics in some small towns, and most don't even have their own doctor.

St. Louis Post-Dispatch
May 25, 2000, Thursday, FIVE STAR LIFT EDITION
MEDICAL ERRORS ARE PATIENTS' NO. 1 FEAR, DOCTOR SAYS HERE
The high cost of hospital care isn't the only thing that patients worry about these days.
The top concern for today's patients is fear that they will be given the wrong drug or wrong dose - an error that could be deadly.
So says Dr. Kenneth Kizer, a leader in the national effort to reduce medical errors.
Kizer spoke in St. Louis Wednesday at a patient-safety conference sponsored by the Gateway Purchasers for Health. He is president and chief executive of the National Forum for Health Care Quality, a nonprofit membership organization formed last year to improve the way health-care errors are measured and reported.

The Washington Post
May 25, 2000, Thursday, Final Edition
OPM Making 'Mental Health Parity' a Priority for Insurance Companies
The health care program for federal employees will soon serve as a testing ground for "mental health parity," an initiative aimed at helping patients obtain increased treatment in an affordable way. If the government program succeeds, it will likely serve as a model for what has emerged as a sensitive, difficult issue facing health care providers and insurance companies across the country.
The Office of Personnel Management, which administers the federal health program, outlined the scope of the effort in a recent "call letter" to insurance companies. It asks the companies to submit their contract proposals by May 31 with an eye to completing negotiations by summer's end.

PR NEWSWIRE
May 24, 2000
Creating a Culture of Safety: NursingCenter.Com to Host Live, Interactive Webcast on Preventing Practice Errors

MEDIA ALERT *** MEDIA ALERT *** MEDIA ALERT Lucian Leape, MD, PhD, David Keepnews, JD, MPH, RN will discuss how failures in the healthcare delivery system contribute to the harm caused by potential or actual errors
Background: The findings of a major study conducted by the Institute of Medicine (IOM) of the National Academy of Sciences found that medical errors kill 44,000 people in U.S. hospitals each year. Another study puts the number much higher, at 98,000. -- Each year, more people die from medical errors than from highway accidents, breast cancer, or AIDS. -- While practice errors are more easily detected in hospitals, they occur in every healthcare setting: day-surgery and outpatient clinics, retail pharmacies, nursing homes, and home care. -- More than 7,000 deaths occur each year from medication errors that take place both in and out of hospitals, exceeding those from workplace injuries. -- According to the IOM study, the majority of medical errors do not result from individual recklessness, but from basic flaws in the way the health system is organized.

Medical Letter on the CDC & FDA
May 23, 2000
Super Panel Examines Errors and Omissions; study on medical errors discussed at eHealthcareWorld conference; Brief Article
2000 MAY 23 - (NewsRx.com) --
A panel of leading industry experts, analysts, and executives in the medical and healthcare arenas discussed at eHealthcareWorld 2000 the escalating rise of errors and omissions in the healthcare industry - the cause of tens of thousands of patients' deaths annually.
The superpanel analyzed telemedical solutions to this challenge in an eHealthcareWorld session titled "Medical Errors Super Panel: The Role of Technology, The Influence of Washington."
"Unfortunately, more people die from medical errors and omission of medication in this country, than from car accidents, breast cancer, or AIDS," said panelist Dr. Molly Coye, of the Lewin Group, who serves on the Quality of Health Care in America Committee of the Institute of Medicine. "This is a crucial issue which needs to be discussed and remedied."

Medical Letter on the CDC & FDA
DATE1: May 23, 2000
May 23, 2000
MEDICAL ERRORS: Super Panel Examines Errors and Omissions
A panel of leading industry experts, analysts, and executives in the medical and healthcare arenas discussed at eHealthcareWorld 2000 the escalating rise of errors and omissions in the healthcare industry - the cause of tens of thousands of patients' deaths annually.
The superpanel analyzed telemedical solutions to this challenge in an eHealthcareWorld session titled "Medical Errors Super Panel: The Role of Technology, The Influence of Washington."
"Unfortunately, more people die from medical errors and omission of medication in this country, than from car accidents, breast cancer, or AIDS," said panelist Dr. Molly Coye, of the Lewin Group, who serves on the Quality of Health Care in America Committee of the Institute of Medicine. "This is a crucial issue which needs to be discussed and remedied."

Medical Economics
May 22, 2000
Scapegoating won't reduce medical errors.
The "culture of blame" surrounding medicine is the biggest impediment to improving patient safety, this veteran advocate warns.
By now, most of your patients have seen the headlines and heard the ominous broadcasts that they are at greater risk from medical mistakes than they'd ever imagined.
The recent Institute of Medicine report has created a firestorm. It concluded that preventable errors cause between 44,000 and 98,000 deaths annually--more than motor vehicle accidents, breast cancer, or AIDS--and are the eighth largest cause of avoidable death in the United States.
While those numbers are startling, they point to a problem the medical community has worried about--and been afraid to talk about--for some time. Now, there's tremendous pressure to "do something" to rectify this "new" crisis. Within a week of the report's release late last year, President Clinton issued an executive memorandum mandating that federal agencies create "a culture of safety and an environment where medical errors are not tolerated." He called on the health care community to reduce errors by 50 percent within five years, as if that goal can be accomplished by fiat.

Drug Topics
May 15, 2000
When drug names spell TROUBLE; Brief Article; Statistical Data Included
It's estimated that one in four med errors involves products that look or sound alike. Is a calamity within your reach?
At some point, most practicing pharmacists experience the breathless dread associated with a medication error. Even minor episodes provide a disturbing reminder that competent practitioners are vulnerable--and that some mistakes prove deadly. The Medication Error Reporting Program (MERP), a cooperative effort of the United States Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP), has catalogued thousands of blunders. Some of these anecdotes are frightening enough to accelerate the steadiest heartbeat. Consider the following reports:
* Mix-ups between Sufenta (sufentanil) and Sublimaze (fentanyl) are blamed for multiple incidents of respiratory arrest.
* A patient with HIV disease and tuberculosis was prescribed ethambutol, 1,000 mg, which is generally taken once a day, but was given a 1,000-mg dose of the antiarrhythmic drug Ethmozine (moricizine) before the mistake was discovered. The usual maximum dosage of Ethmozine is 900 mg/day in three divided doses.

Medical Industry Today
May 15, 2000, Monday
Study Finds High Drug Prescription Errors at Outpatient Clinics
Boston researchers studying the drug prescribing patterns of four ambulatory medical clinics found that the rate of errors was nearly 17 percent, mostly because of dosing mistakes, according to findings presented last week at an internal medicine meeting.
The researchers found 64 medication errors in the 384 prescriptions studied (16.7 percent) over a four-week span, Reuters reported. The error rate was 24 percent for new prescriptions and 10 percent for refills, reported Dr. Tejal Gandhi of Brigham and Women's Hospital in Boston. She said 4 percent of prescriptions resulted in adverse drug reactions.

TELEGRAM & GAZETTE
May 12, 2000 Friday, FINAL EDITION
Legislation targets errors, safety;
Center would develop standards
State Sen. Richard T. Moore, D-Uxbridge, and state Rep. Harriette L. Chandler, D-Worcester, have introduced legislation that would establish a center to focus on increasing patient safety and reducing medical errors.
The center would be named the Betsy Lehman Center for Patient Safety and Medical Error Reduction in honor of the late Boston Globe health columnist who died in 1994 after receiving an overdose of chemotherapy while undergoing experimental treatment for advanced breast cancer at the Dana-Farber Cancer Institute.
Ms. Lehman also had been a food editor and an editorial writer at the Worcester Telegram.
We have a fractured reporting system for medical errors now,'' said Mr. Moore. Hospitals report errors to the state Department of Public Health while each medical profession- doctors, nurses, pharmacists- reports to various state boards.

Scripps Howard News Service
May 11, 2000, Thursday
Prescription for penmanship
Dr. John Williams never imagined part of his medical training would involve learning the finer points of cursive italic alphabet.
That was until class started.
"The Z," instructor Barbara Getty said behind the glare of an overhead projector. "It is clean-cut. One stroke, no lift."

The Times Union (Albany, NY)
May 11, 2000, Thursday, THREE STAR EDITION
Poll: Consumers want access to malpractice records
A new poll shows that more than 90 percent of New Yorkers want easier access to information about their physicians' medical malpractice histories and more accountability by doctors who make mistakes.
The results of the poll were released Wednesday by a coalition of consumer groups that has been lobbying for legislation to protect against medical errors, which kill an estimated 7,000 people in the state and up to 98,000 across the country each year.
''There's clear evidence that the public is with us,'' said Blair Horner of the New York Public Interest Research Group, about the Zogby International poll of 700 New Yorkers. ''It seems like it should be a no-brainer.''

Ventura County Star (Ventura County, Ca.)
May 11, 2000, Thursday
Class aims to treat notoriously wretched writing by doctors
Prescription for penmanship
Dr. John Williams never imagined part of his medical training would involve learning the finer points of cursive italic alphabet.
That was until Tuesday night.
"The Z,"instructor Barbara Getty said behind the glare of an overhead projector. "It is clean-cut. One stroke, no lift."

The Boston Globe
May 10, 2000, Wednesday ,THIRD EDITION
PATIENT SAFETY CENTER ADVANCES GROUPS DIVIDED ON DEFINING ERRORS
Support is building in the state Legislature to create a first-in-the-nation agency aimed at reducing medical errors that kill as many as 1,900 Massachusetts patients annually and injure countless others.
The Legislature's joint health care committee voted yesterday to establish the Betsy Lehman Center for Patient Safety and Medical Error Reduction, named after a Boston Globe health columnist whose 1994 death from a chemotherapy overdose is credited with stimulating a national movement to prevent such medical injuries. Several Boston hospitals agree to provide second opinions abroad over the Internet. D1.

Omaha World-Herald
May 9, 2000, Tuesday BULLDOG EDITION
Expert: Attitude Critical To Reduce Medical Errors
Reducing medical errors in the United States will depend on the mind-set of everyone from doctors to members of the public, a physician-researcher said Monday in Omaha. If there's a "gotcha" attitude, nothing much is likely to improve, said Dr. Carolyn Clancy of the federal Agency for Healthcare Research & Quality. "Errors will be hidden," she said. But errors can be reduced if reporting is seen as a way to learn from what has happened and prevent future mistakes, she said. Clancy heads the agency's Center for Outcomes and Effectiveness Research in Rockville, Md. The center funded a recent Institute of Medicine study on medical errors. It found that between 44,000 and 98,000 Americans die each year as a result of medical errors. That means more people die from medical errors than from motor vehicle accidents or diseases such as breast cancer. Congress has charged the agency with leading federal efforts to improve the quality of health care, including the reduction of medical errors. The study found that errors are related to the complexity of today's health care, said Clancy, who also holds appointments on two university faculties. There's no system - at least not yet - to ensure that the necessary interaction and information-sharing always occur within the array of health-care people now involved in patient care, she said. Christine G. Williams, director of the federal agency's Office of Health-Care Information, said the Institute of Medicine report is based on errors that occurred within hospital settings.

The Patriot Ledger (Quincy, MA)
May 9, 2000 Tuesday ROP Edition
More may be dying from medical errors
WASHINGTON -- A widely publicized report saying that as many as 98,000 people die each year in the United States from medical errors is conservative, and the number is probably much larger than that, one of the study's authors said yesterday.
The estimate by the Institute of Medicine is low because it looked only at deaths of patients at hospitals, said author Janet M. Corrigan, IOM's director of health care services. The Institute is a private, nonprofit organization that provides health policy advice under a congressional charter to the National Academy of Sciences.

The Times Union (Albany, NY)
May 9, 2000, Tuesday, THREE STAR EDITION
Estimate for medical error deaths could be low
WASHINGTON -- A widely publicized report saying that as many as 98,000 people die each year in the United States from medical errors is conservative, and the number is probably much larger than that, one of the study's authors said Monday.
The estimate by the Institute of Medicine (IOM) is low because it looked only at deaths of patients at hospitals, said author Janet M. Corrigan, IOM's director of health care services. The Institute is a private, nonprofit organization that provides health policy advice under a congressional charter to the National Academy of Sciences.

Star Tribune (Minneapolis, MN)
May 3, 2000, Wednesday, Metro Edition
The Observatory;
Medical 'errors' report misrepresents the research, doctor says
Like many physicians, Dr. Troyen Brennan was disturbed by the recent report that medical mistakes cause between 44,000 and 98,000 deaths in American hospitals every year.
For Brennan, a professor of medicine at Harvard University in Cambridge, Mass., the problem was the numbers. To him, they were highly misleading in the way that they were presented to the public in November in the widely cited report, "To Err is Human," by the prestigious Institute of Medicine in Washington, D.C.
He took that personally, because the numbers were based entirely on two studies that he helped conduct at hospitals in New York, Colorado and Utah.
Brennan, writing in the New England Journal of Medicine last month, argued that the now-famous report on medical mistakes made some serious mistakes of its own, jumping to conclusions that the data don't support.

Business Wire
May 2, 2000, Tuesday
Healthcare Professionals Discuss State of Medical Errors Today; HCPro Releases Results of Follow Up Medical Error Survey of Health Professionals at eHealthcareWorld;
eHealthcareWorld 2000
(www.hcpro.com) HCPro, the healthcare professional's partner in success, today announced the results of a follow-up survey on medical errors at eHealthcareWorld, the industry's most progressive and comprehensive forum dedicated to the convergence of healthcare and the Internet held in Las Vegas. A plenary session at the conference (4:30-5:30 p.m.) is devoted entirely to the subject of medical errors.
According to a 1999 Institute of Medicine report, medical errors in U.S. hospitals account for 44,000 to 98,000 deaths each year. HCPro surveyed 573 CEOs, physicians, nursing directors, and other health professionals concerning medical errors. The surveys found that 71% of physicians reported having made at least one medical error. In addition, 98% of CEO's surveyed reported that medical errors had occurred within their facility.

ADC News and Solutions
May 1, 2000
ADC--it could be a matter of life and death;
The Institute of Medicine recommends broader use of bar codes in hospitals to reduce avoidable fatal medical errors by 50% in 5 years.
It is estimated that between 44,000 and 98,000 deaths can be attributed to medical error in U.S. hospitals annually, says a recent report: "To Err is Human: Building a Better Health System." Of these deaths, more than 7,000 a year are from medication errors that include prescribing, dispensing, and administrating the wrong drug or dosage to the patient, or administering a drug at the wrong time, says the Institute of Medicine (IOM), a private, non-profit institution that dispenses medical advice that authored the report.
The IOM report identifies the utilization of bar coding as an effective remedy to these types of errors. "Bar coding is a simple way to ensure that the identity and dose of the drug are as prescribed, that it is being given to the right patient, and that all of the steps in the dispensing and administration processes are checked for timeliness and accuracy."
A minimum goal is set in the IOM report for a 50% reduction in errors over the next 5 yr. "It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives, and meet the challenges ahead," says William Richardson, chair of the committee who wrote the report and chief executive officer of the W.K. Kellogg Foundation.
Bar code applications can ensure accurate and complete information regarding indicated drug names, dosages, administration frequency, as well as prevent the administration of drugs that are contraindicated.

AORN Journal (Association of Operating Room Nurses) (Association of Operating Room Nurses)
May 1, 2000
Solutions at your fingertips; Statistical Data Included
Institute of Medicine (IOM) committee members reported in testimony before the 106th Congress that medical mistakes rank eighth among the leading causes of death in the United States.(1) A report released in November 1999 discloses alarming statistics that medical errors are killing between 44,000 and 98,000 people in US hospitals each year.(2) The statistics do not include errors that may occur in settings other than hospitals (eg, physician's offices, extended care facilities). Medical errors are believed to be the nation's leading cause of death and injury.(3)
All medical errors do not result in death, permanent disability, or suffering, however. Media reports result in more questions than answers for our patients because information is presented as though adverse events are common. Institute of Medicine committee members reported that they believe 95% to 98% of the errors are "system errors," meaning they are related to equipment, procedures, or job designs. It is believed that more than 7,000 patients die each year from medication errors that occur within and outside of the hospital.(4) One expert clarified responsibilities of those involved in patient care by stating "It's the little mistakes that cause the big problems in patient safety."(5)

FOR THE PHARMACIST
May, 2000
May, 2000 - June, 2000
IOM Takes Aim at Medication Errors

Medical Industry Today
May 1, 2000, Monday
Authors Try to Revive Interest in Autopsies
Staff reports
Despite a heightened interest in preventing medical errors, the number of autopsies performed in the United States has declined, according to a newly published article.
The authors say that the decline may be attributed to two factors--medical advances that have led to the perception that autopsies aren't needed, as well as a "culture of defensiveness." Nevertheless, they state that "when the final outcome is death," the autopsy remains the best available tool to evaluate diagnostic accuracy.
The article--"Medical Error and Outcomes Measures: Where Have All the Autopsies Gone?"--is posted on Medscape General Medicine, a peer-reviewed medical journal found at www.medscape.com. The article was written by Dr. Elizabeth C. Burton, a member of the National Quality Scholars Fellowship Program at San Francisco Veterans Affairs Medical Center, and Peter N. Nemetz, a member of the Strategy and Business Economics Faculty of Commerce and Business Administration at the University of British Columbia.

Modern Physician
May 1, 2000, Monday
Virtual vigilance; Computers and simulators help reduce medical errors
During a respiratory emergency in the operating room, an anesthesiologist has only a few minutes to diagnose and fix the problem or the patient might die. If the patient's airway is obstructed, the anesthesiologist might use a flexible bronchoscope to intubate.
It's a difficult procedure to master, particularly in the hands of a nervous resident with little or no experience.
Using computer simulation, an anesthesia resident at Children's Hospital Oakland (Calif.) can master the bronchoscope before trying it in the operating room. The resident inserts the device -- a long, flexible tube with a fiber-optic lens -- into the nose of a robotic faceplate. A computer screen displays what the resident would see inside a real patient's lungs. The resident then snakes the spaghetti-like tube through the virtual patient's airway.

The Nurse Practitioner
May 1, 2000
Medical Errors Hit Home.
Related personal events can make statistics and issues more credible. A recent experience I had as a patient has made the media reporting of "Medical Errors Blamed for Killing Tens of Thousands of Americans Each Year" both urgent and believable.
How Many Errors Can You Find?
Last summer, while I was camping beside the caves at Lake Powell, Utah, a bat landed on, scratched, and probably bit the top of my head. Because I had recently edited an article on rabies (see The Nurse Practitioner, April 1999, pages 91-107), I knew I should seek medical attention.

PR Newswire
May 1, 2000, Monday
Pennsylvania Department of Health Releases Guidelines to Hospitals For Reporting Medical Errors, Other Serious Incidents
To help ensure the safety of patients in Pennsylvania's more than 200 hospitals, the Pennsylvania Department of Health today announced new guidelines for reporting serious incidents that compromise patient care, including medical errors, to hospital administrators statewide.
"Most medical errors are caused by system problems -- not by human error alone," said Secretary of Health Robert S. Zimmerman Jr. "We're working with hospitals to help them ensure the quality of their patients' care. The health and safety of Pennsylvanians seeking medical care is our top priority."
Health Department officials recently issued guidelines, a sample reporting form, and a copy of Chapter 51, the state regulation on serious incidents, to hospital administrators to improve the reporting and state follow-up of incidents that could seriously compromise patient safety or quality assurance.
Chapter 51, which became effective in June 1998, requires Pennsylvania health-care facilities to report any situation or event that could compromise seriously the health and safety of a patient, and to describe corrective steps.
Last November, the National Academy of Science's Institute of Medicine released a report on medical errors in the United States, "To Err is Human." This report, largely focused on hospitals, estimated that between 44,000 and 98,000 deaths occur each year nationwide as a result of medical errors.
The Institute of Medicine defined a medical error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve a goal. The Department of Health requires the reporting of serious incidents that include deaths due to injury, suicide, malnutrition, dehydration or medication errors; surgeries performed on the wrong patients or body parts; unlicensed practices of regulated professions; rapes; infant abductions; patient abuses; or strike notices.

Business Wire
April 28, 2000, Friday
Autopsies Can Help Reduce Misdiagnoses Which Cause Medical Errors, Patient Deaths, According to New Medscape Peer-reviewed Article
U.S. Autopsy Rates Have Declined by More than 50% Since Early 1970's,Despite Heightened Interest in Patient Safety, Error Prevention and Quality Health Care
A just-released peer-review article reveals that advances in medical technology, as well as a defensive medical culture, may be responsible for the declining number of autopsies performed in the United States.
The information value of autopsies, however, is gaining increased attention from the medical community as medical errors leading to patient deaths continue to rise.
According to the article's authors, the discrepancies between ante mortem and postmortem diagnoses - at the average rate of 40% - call attention to the value autopsies provide in terms of conclusive clinical information that can ultimately help lead to a decrease in ante mortem misdiagnoses.
The exclusive article, "Medical Error and Outcomes Measures: Where Have All the Autopsies Gone?" has just been posted on Medscape General Medicine (MedGenMed) at http://www.medscape.com/MedGenMed/autopsies, the Internet's pioneering, primary-source, peer-reviewed medical journal. MedGenMed is found on medscape.com, www.medscape.com, a leading provider of authoritative health and medical information on the Internet since 1995.

BestWire
April 25, 2000
NCQA SUGGESTS CHANGE IN RULES TO INCREASE PATIENT SAFETY
WASHINGTON (BestWire) - The National Committee for Quality Assurance said it had proposed a modification to its 2001 accreditation program that is intended to improve patient safety and reduce medical errors. The modification would require managed-care companies to provide comprehensive descriptions of how they address patient concerns, such as poorly coordinated care and adverse drug interactions, the committee said in a statement.

FOX NEWS NETWORK
SHOW: THE O'REILLY FACTOR (20:35 ET)
April 21, 2000, Friday
Should the Government Force Hospitals to Report Medical Mistakes?
THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
GINGRICH: Thanks for staying with us. I'm Newt Gingrich in for Bill O'Reilly.
A recent study by the Institute of Medicine found that as many as 98,000 deaths occur every year because of medical errors made by doctors, nurses, and hospitals. The White House has called for mandatory reporting of medical mistakes, but some, like the AMA, say public disclosure would open the floodgates to lawsuits against health-care providers.

Newsday (New York, NY)
April 18, 2000, Tuesday ALL EDITIONS
THE DOCTOR'S IN / A PRESCRIPTION FOR AVOIDING MEDICAL ERRORS
Q. I saw the recent report about medical errors being responsible for thousands of deaths in hospitals each year. What can I do to protect myself?
A. The Institute of Medicine estimated that medical errors are responsible for as many as 44,000 to 98,000 deaths in hospitals each year. The Agency for Healthcare Research and Quality has issued tips for how you can prevent medical errors. Here's an abridged version:
1. Be actively involved in your health care.

Drug Topics
April 17, 2000
EXPLORING ERRORS : Experts comment on the most common med errors, ways to fix them, and legal claims against them; Brief Article
What are the most common medication errors? Are more drug mistakes being made today? What should a pharmacy know about legal liability when it comes to med errors? How liable is the technician? How can drug errors be prevented or reduced?
Those were some of the hot potatoes experts in med-error detection, reporting, and litigation fielded at two separate sessions held during the American Pharmaceutical Association's annual meeting last month in Washington, D.C. Both sessions drew large crowds.
Interest in the subject was spurred by a recent Institute of Medicine report, which found that between 44,000 and 98,000 people die yearly from medical errors, including medication errors. At one of the sessions, Michael Cohen, president of the Institute for Safe Medication Practices, called the IOM report "probably one of the most important" developments that has ever happened to the health-care professions.
At the same time, Cohen re-affirmed ISMP's objection to the IOM recommendation calling for mandatory reporting of med errors, at least in cases involving serious harm or death. "Med errors are the property of the system as a whole, rather than the results of the acts or omissions of the people within the system," he emphasized. "Performance improvement requires changing the system, not the people."

THE BALTIMORE SUN
April 14, 2000, Friday ,FINAL
On health care, paying Cadillac prices for a Pinto
MANY AMERICANS lament the high cost of U.S. health care, but console themselves with the thought that, well, it's expensive because it's the best care available in the world. It sounds good, but it's not true.
At least, not when you look at the results. How do the outcomes of our health-care system stack up against our Western, industrialized counterparts in Canada and Europe? In a recent Johns Hopkins study that measured death rates and other indicators of health, the United States finished nearly last -- 12th out of the 13 countries studied.

Business Wire
April 11, 2000, Tuesday
Symbol Technologies, McKessonHBOC Automated Healthcare Announce Medication-Match Solution to Reduce Errors
Symbol's Mobile Computers, Wireless LAN Technology, McKesson-HBOC's ROBOT-Rx and AcuScan-Rx Systems are Utilized at V.A. Medical Center
Symbol Technologies, Inc. (NYSE: SBL) announced today at the HIMSS trade show that it is teaming with McKessonHBOC Automated Healthcare to provide a point-of-care patient-to-medication match system that will dramatically reduce medication errors and save lives. This solution addresses several national initiatives including a Veterans Administration (V.A.) mandate to bar code and scan patient medications at the bedside, and a challenge to the healthcare industry by President Clinton.
The subject of medical errors has gained recent national attention due to a study by the Institute of Medicine (IOM) published late last year. The IOM found that medical errors kill an estimated 44,000 to 98,000 Americans every year, including 7,000 deaths from medication-related errors alone. The study also stated that medical errors cost as much as $29 million and are the fifth leading cause of death, ahead of AIDS, breast cancer and motor vehicle accidents.

Business Insurance
April 10, 2000, Monday
Best outcomes sorely needed in medicine
"Demanding Medical Excellence: Doctors and Accountability in the Information Age"
By Michael L. Millenson
University of Chicago Press
451 pages
800-621-2736
$16
What's one of the leading causes of death and injury in the United States? Doctors. And what's being done about it? Not enough.
This, in a nutshell, summarizes a newly issued paperback edition of "Demanding Medical Excellence: Doctors and Accountability in the Information Age." Its author, Michael Millenson, a veteran health care journalist turned consultant, plunges headlong into the complex problem of delivering high-quality medical care in this thoroughly researched and highly readable book.

The Industry Standard
April 10, 2000
Getting the Record Straight
SEATTLE- Heart surgery resident Alex Farivar is 30 hours into his shift at the University of Washington Medical Center when he finishes his rounds and retreats bleary-eyed to the residents' room with a handful of barely legible notes that detail patients' conditions.
In the past, these notes would have gone straight into Farivar's patients' files, leaving subsequent caregivers to puzzle over his handwritten observations and directions. Instructions that were still unclear might have led to a time-consuming round of phone tag as doctors and nurses tried to clarify what Farivar jotted down. Worse, his notes might have been misinterpreted and patients given the wrong treatments.
Now, instead of adding to the sheaf of papers in a 70-year-old heart patient's chart, Farivar sits at a computer in the small room where residents catnap and calls up an electronic version of the woman's medical record. Made by Seattle-based Elixis, the WebCoder online medical record provides a complete - and readable - treatment and medication history. Farivar adds his observations and directions for treatment by clicking on a series of menus with titles like Vital Signs, Current Medications and Assessment and Plan, then digitally signs the record. Authorized doctors and nurses can access the record online from any location.

Omaha World-Herald
April 7, 2000, Friday SUNRISE EDITION
Bill Calls for Reports On Medical Errors
With an estimated 44,000 to 98,000 Americans dying each year from mistakes made by doctors, nurses and other health professionals, Midlands senators introduced a bill Thursday that would require many health workers to formally report their medical errors. Sens. Charles Grassley, R-Iowa, and Bob Kerrey, D-Neb., joined two Senate colleagues in introducing the bill, which would require reporting of errors by hospitals and other health-care facilities that provide services purchased by Medicare and Medicaid. The senators said medical errors are among the leading causes of death in this country, killing more people than car accidents, breast cancer or AIDS. But the issue hasn't prompted the "outrage that you might expect," Grassley said at a press conference, because most Americans don't realize the extent of the errors. "What we're attempting to do through reporting is provide patients with enough information that they will be able to tell who's doing a good job and who's not," Kerrey said at the press conference. Their bill resembles one in the House and is similar to Senate legislation introduced in February by Sens. Tom Harkin, D-Iowa, and Arlen Specter, R-Pa. The Grassley-Kerrey bill would require hospitals and health facilities providing services covered by Medicare or Medicaid to report errors that lead to death or serious injury and the corrective steps taken to prevent further accidents. The reports would remain confidential. A facility would have two years to implement a safety program and take action to address safety problems.

The Washington Post
April 6, 2000, Thursday, Final Edition
Managed Care Ad Sparks Sharp Rebuke; Critics Accuse HMO Group Of Disrupting Hill Debate
politicians and medical groups supporting managed-care legislation before Congress.
The ad, paid for by the American Association of Health Plans (AAHP), is aimed mainly at House and Senate conferees who have been huddling in an effort to resolve differences over "patients' rights" legislation. The stronger House version would allow patients to file lawsuits against health insurance companies that deny adequate care.

FDCH Political Transcripts

April 6, 2000, Thursday
TYPE: NEWS CONFERENCE
U.S. SENATOR CHARLES GRASSLEY (R-IA) HOLDS NEWS CONFERENCE ON MEDICAL ERRORS IN THE MEDICARE AND MEDICAID PROGRAMS
SPEAKER:
U.S. SENATOR CHARLES GRASSLEY (R-IA),
LOCATION: WASHINGTON, D.C.
SENATORS HOLD NEWS CONFERENCE ON MEDICAL ERRORS IN THE
MEDICARE AND MEDICAID SYSTEMS

APRIL 5, 2000

SPEAKERS: U.S. SENATOR CHARLES GRASSLEY (R-IA)
U.S. SENATOR JOSEPH LIEBERMAN (D-CT)
U.S. SENATOR BOB KERREY (D-NE)
U.S. SENATOR RICHARD BRYAN (D-NV)

*
GRASSLEY: First of all, we thank you all very much for coming on an issue that is getting a lot of attention and ought to and deserves very much the attention of the Congress of the United States.

I, first of all, I want to give an apology to my colleagues and to all of you that when I make a statement I'm going to have to go back to chair the China trade hearing that we have. So if that -- that's understanding, my staff will be around if there's any questions that anybody in the media has of me.

First of all, to all my colleagues who are here in a combined bipartisan effort, I thank them for giving attention to this issue and for us -- our working together on it.

We start usually with the Institute of Medicine report, with the large number of deaths because of medical errors. I think this report has served a very valuable service. It has raised consumer awareness about medical errors.

NOTES:
Unknown - Indicates speaker unknown.
Inaudible - Could not make out what was being said.
off mike - Indicates could not make out what was being said.

ABC NEWS
SHOW: 20/20 WEDNESDAY (10:00 PM ET)
April 5, 2000, Wednesday
WHAT THE DOCTOR LEFT BEHIND; MEDICAL MISTAKES CAUSE SEVERAL DEATHS AND SEVERE INJURY
WHAT THE DOCTOR LEFT BEHIND
Announcer: From Times Square in New York, Diane Sawyer and Charles Gibson.
DIANE SAWYER, co-host:
Good evening and welcome to 20/20 WEDNESDAY. We're so glad you could have join us. Tonight, harrowing tales from the operating room, told by patients who have lived through some of the most bizarre experiences you can imagine. Surgical tools left inside them, and even the wrong part of their body operated on.
CHARLES GIBSON, co-host:
Diane, the highly respected institute of medicine says these kinds of medical mistakes are happening way too often. This year, one in 10 of us will enter a hospital to have surgery. So the question becomes, how can you protect yourself? Well, you're about to find out as Chris Wallace investigates some medical mishaps that will leave you speechless.

Medicine & Health
April 3, 2000
Field Report on Reducing Medical Errors: Providers Already Showing It Can Be Done.
Legislators, lobbyists for health care trade associations, and agency experts are entangled in a complex debate in Washington over the reporting of medical errors. Just this week, the Assn. of American Health Plans announced at a Washington press conference a major, and controversial, advertising campaign to urge that reducing the frequency and severity of such errors should zoom to the top of the national health care agenda.
But outside the Beltway, perspectives on this most serious of patient care topics is that the time for debate has long past. Indeed, the message coming from those working on the problem out in the industry is that there is now widespread consensus on the need to make major progress in reducing the medical errors that continue to plague the health care system, inconveniencing, injuring, and even killing patients.

AORN Journal (Association of Operating Room Nurses)
April 1, 2000
Nursing Certification Linked to Improved Patient Care; Brief Article
The largest study ever conducted of US and Canadian nurses who hold professional certification revealed that certification is a key factor in reducing health care errors, according to a Feb 11, 2000, press release from the American Nurses Credentialing Center. The study comes on the heels of an Institute of Medicine study that found that 44,000 to 98,000 people die each year as a result of health care errors, according to the release.
Study participants were selected randomly from 20 of the 23 nurse certifying bodies that represent more than 350,000 certification holders. More than 19,500 certified nurses provided data about demographic, personal, and professional outcomes, as well as performance outcomes enabled by certification. The nurses -- who were employed in every venue of practice -- represented more than 50 different certification credentials. The majority of nurses reported that certification was voluntary for their practice.

The Atlantic Monthly
April 1, 2000
Government: Regulation by Shaming.
Forcing companies to disclose health and safety information can improve customer choices and industry practices-but it can also distort perceptions of what should be changed
The federal government phased out the use of lead in gasoline and household paint twenty years ago, but it is still present in many products. Makers of china, water faucets, and calcium supplements have recently gone to great lengths to reduce the amount of lead they use. What is remarkable is that these efforts are not the usual attempts to avoid stiff penalties associated with new federal rules. Instead they are a response to a California law that requires companies to provide information to the public about practices that remain perfectly legal. Corporations all over the country are feeling the effects of an increasingly powerful but unheralded government policy tool: mandatory disclosure.

Business & Health
April 1, 2000
Murder is a very strong word, but the fact remains that mistakes kill thousands of people each year. What are health professionals doing to reduce the toll?Brief Article
It's a sad truth that hospital stays are hazardous to your health. Most anyone in the health care industry has known this for years, but the Institute of Medicine (IOM) made headlines when it quantified the problem last December. Human errors claimed at least 44,000 and perhaps as many as 98,000 lives in the U.S. in 1998. Even the lower number exceeds the death toll from vehicle accidents, breast cancer or AIDS.
Extrapolating from studies in New York, Colorado and Utah, the IOM calculated that the chances of being injured increased about 6 percent for each day of hospital stay. Therefore, during a three-day hospital stay, the odds are nearly one in five that some caregiver will make a mistake that hurts a patient.
Generally, injuries are caused by mistakes in technique, diagnosis or treatment, according to the IOM report. Medication errors are the most common. A January 2000 report by the General Accounting Office found that adverse drug events varied from less than one to nearly 30 per 100 admissions, depending upon the study and the definitions used. The most common were overdosing or underdosing and prescribing drugs to which patients were allergic or that interacted adversely with other medications.

Medical Laboratory Observer
April 1, 2000
Push is on to reduce medical errors; additional money wanted for the CDC; new needlestick report offers guidance; Brief Article
Make medical errors public
Efforts are underway to reduce the number of deaths from preventable medical errors. The White House recently offered a 5-point plan designed to help trim medical mistakes by 50% over 5 years. The plan would require hospitals to publicly report all medical errors that result in death or serious injury. As envisioned by Mr. Clinton, individual states would implement the new error reporting system. Some states already have mandatory reporting systems in place.
Hospital and physician office labs in particular have a stake in the issue because the crackdown promises to affect them as well as other providers.

The Spokesman-Review (Spokane, WA)
April 1, 2000, Saturday, SPOKANE EDITION
Changes urged in how hospitals handle drugs;
Pharmacy expert offers advice on preventing mistakes that kill
The place where Americans should feel safest could be more dangerous than they suspect.
A report by the Institute of Medicine last year ranked medical mistakes in hospitals as the fourth most common cause of death in the United States, above AIDS and highway accidents.
The report estimated 44,000 to 98,000 people are killed annually due to avoidable errors. That equals three jumbo jets crashing every two days.

The Western Journal of Medicine
April 1, 2000
Editor's Pick; article on medical error analysis
In the practice of medicine, accidents happen. In fact, they are alarmingly common. Last November, a report from the Institute of Medicine claimed that between 44,000 and 98,000 Americans die from medical errors each year.

The Western Journal of Medicine
April 1, 2000
Senators introduce bill to improve patient safety; Error Reduction and Improvement of Patient Safety Act
A bill to improve patient safety is being introduced by two senators, following the publication last November of a report from the Institute of Medicine of the National Academy of Sciences, which claimed that medical errors kill from 44,000 to 98,000 Americans each year.
Mistakes involving the prescribing and dispensing of drugs were the most common errors, resulting in 7000 deaths a year, the report said. President Clinton immediately ordered the Federal Quality Interagency Task Force, which oversees federal health programs for 85 million Americans, to adopt all feasible techniques for reducing medical errors and to report back within 60 days. He has also included more than $ 50 million in the federal budget in new funding for government programs to reduce the nation's rate of medical errors.

Policy Papers
Reducing Errors in Health Care: Translating Research Into Practice
April, 2000
ISSUED-BY: Agency for Healthcare Research and Quality (HHS)
AHRQ Publication No. 00-PO58
Medical errors are responsible for injury in as many as 1 out of every 25 hospital patients; an estimated 48,000-98,000 patients die from medical errors each year. Errors in health care have been estimated to cost more than $5 million per year in a large teaching hospital, and preventable health care-related cost the economy from $17 to $29 billion each year.
AHRQ research has shown that medical errors may result most frequently from
LOAD-DATE: March 13, 2001

THE ORLANDO SENTINEL
March 31, 2000 Friday, METRO
'REPORT CARDS' SOUGHT TO TRACK HOSPITAL MISTAKES;
UNDER TWO BILLS BEING CONSIDERED, FLORIDIANS WOULD HAVE INTERNET ACCESS TO SUCH DATA.
TALLAHASSEE - Florida consumers could get information off the Internet that might help save their lives under two hospital "report card" bills being considered by the Legislature.
Proponents say the legislation could help curb the number of medical blunders that nationally cause at least 44,000 annual deaths and injuries - more than the death toll linked to AIDS, breast cancer or highway accidents, according to one prominent study.

Sun-Sentinel (Fort Lauderdale, FL)
March 31, 2000, Friday, Broward Metro EDITION
POST HOSPITAL 'REPORT CARDS' ON INTERNET, TWO BILLS URGE
Florida consumers could get information off the Internet that might help save their lives under two hospital "report card" bills being considered by the Legislature.
Proponents say the legislation could help curb the number of medical blunders that nationally cause at least 44,000 annual deaths and injuries -- more than the death toll linked to AIDS, breast cancer or highway accidents.
Sponsored by Rep. Larry Crow, R-Dunedin, and Sen. Ginny Brown-Waite, R-Brooksville, the bills (HB 1851 and SB 1858) would require that hospitals report all medical accidents to the Agency for Health Care Administration and that the information be made public in report cards on the Internet.

Business Wire
March 22, 2000, Wednesday
Health Care Professionals Overwhelmingly Fear Mandatory Reporting of Medical Errors
HCPro Announces Results of Opinion Survey Taken in Response to President Clinton's Plan to Reduce Medical Errors
HCPro (www.hcpro.com), the healthcare professional's partner in success, today announced the results of a web-based opinion survey on medical errors. The survey was devised in response to President Clinton's February 22 report, "Doing What Counts for Patient Safety." The President proposes mandatory reporting of medical errors that lead to serious injury or death and supports legislation to protect the confidentiality of those making and reporting the errors.

The Hill
March 22, 2000 Wednesday
SECTION: SPECIAL SECTION; Health Care; Pg. 26
Medical mistakes more deadly than AIDS
Last November, the Institute of Medicine (IoM) published a report on medical errors entitled, "To Err is Human: Building a Safer Health System." The report takes a serious look at the prevalence and causes of medical mistakes and recommends some significant changes.
Based on earlier studies, the IoM estimated that between 44,000 and 98,000 people die each year from medical errors. To put these numbers in perspective, it would make medical errors the eighth leading cause of death in the United States, ranking medical mistakes as more deadly than auto accidents, breast cancer or AIDS.

PR Newswire
March 21, 2000, Tuesday
Better Communication Technology Could Help Reduce Medical Errors
At a time when President Clinton has announced that he will order all hospitals in the United States to take steps to reduce medical errors, Motorola has developed a message alert system that could help physicians and hospitals reduce errors that have reportedly caused the deaths of tens of thousands of people each year.
The new system, in its final stages of development, could significantly increase the timeliness of delivering critical patient information to physicians. This enhanced communication method could play an integral role in reducing medical errors.
DocLink(TM), being developed by Motorola's Healthcare Communications Solutions group, is in its final stages of testing and is designed to help facilitate the communication needs of physicians. DocLink is essentially engineering the industry's communications processes, utilizing Motorola's communications, software development and systems integration expertise.
"Inadequate communication technology is considered one of the factors contributing to the medical errors problem," said Jim Hubbard, business director of Motorola's Healthcare Communications Solutions group. "More effective and timely communication between physicians, labs and pharmacies creates the need for a better system that can assist physicians and hospitals in obtaining critical information on an immediate basis."
The DocLink system completed its "alpha" test at Washington University School of Medicine and its premier teaching institution, Barnes-Jewish Hospital early last year. The DocLink system was well received by the pharmacists who participated in the alpha test, according to Tom Bailey, MD, FACP, director of Medical Informatics.
The results of the DocLink system alpha test showed a reduction in cycle time (measured from "drug order start to drug order stop").

PR NEWSWIRE
March 21, 2000
Better Communication Technology Could Help Reduce Medical Errors

SCHAUMBURG, Ill., March 21 /PRNewswire/ -- At a time when President Clinton has announced that he will order all hospitals in the United States to take steps to reduce medical errors, Motorola has developed a message alert system that could help physicians and hospitals reduce errors that have reportedly caused the deaths of tens of thousands of people each year.
The new system, in its final stages of development, could significantly increase the timeliness of delivering critical patient information to physicians. This enhanced communication method could play an integral role in reducing medical errors.
DocLink(TM), being developed by Motorola's Healthcare Communications Solutions group, is in its final stages of testing and is designed to help facilitate the communication needs of physicians. DocLink is essentially engineering the industry's communications processes, utilizing Motorola's communications, software development and systems integration expertise.

Chicago Tribune
March 19, 2000 Sunday, CHICAGOLAND FINAL EDITION
CREDIBILITY FACTOR;
CERTIFICATION BOOSTS NURSES', PATIENTS' CONFIDENCE
Improvement in patient-care and a decrease in errors have been linked to nursing certification in a new study of American and Canadian nurses.
The study, conducted by the Nursing Credentialing Research Coalition in Washington, D.C., found that certification also has a positive effect on nurses' earnings.

The Patriot Ledger (Quincy, MA)
March 18, 2000 Saturday All Editions
Patients at risk ;
Hospital errors raise health concerns
First of four parts
Doctors at Milton Hospital were performing an operation in May when they had to stop to put out a fire in the patient's incision.
The surgeon was doing a tracheostomy, installing an oxygen tube through an opening in the patient's neck and windpipe to help him breathe.
When the doctor cut into the man's neck and injected a painkiller into his trachea, a spark from a surgical tool ignited oxygen in a temporary breathing line. "Fire!" screamed a technician.
Medical workers quickly smothered the fire, but not before the man suffered burns to his mouth and inside his trachea and bronchial tubes.

Federal Document Clearing House Congressional Testimony
March 16, 2000, Thursday
TESTIMONY March 16, 2000 FRED UPTON HOUSE COMMERCE OVERSIGHT AND INVESTIGATIONS ACCESS TO MALPRACTICE DATABASE
The Honorable Fred Upton Opening Statement Hearing of the Subcommittee on Oversight and Investigations "Assessing the Operation of the National Practitioner Data Bank" March 16, 2000 Ladies and gentlemen, welcome to today's Oversight and Investigations Subcommittee hearing on "Assessing the Operation of the National Practitioner Data Bank." We will hear today from Mr. Tom Croft, Director of the Division of Quality Assurance of the Health Resources and Services Administration. He oversees the administration of the National Practitioner Data Bank, and I am looking forward to discussing ways in which we can make the data bank a more effective tool in the improvement of health care quality in this nation. The National Practitioner Data Bank was created by Congress in 1986 in response to several factors-the increasing occurrence of medical malpractice litigation and the need to improve the quality of medical care by increasing the willingness of physicians to participate in diligent peer review programs. The data bank law does this by shielding physicians from liability from antitrust and private damage suits when they are engaged in peer review. By creating a nationwide flagging system the bank was designed to address the problem of physicians who lose their licenses or face other discipline in one state simply moving to another state to practice. Today's hearing is particularly timely and important in light of the recent release of the Institute of Medicine's report, To Err is Human. This report came to the startling conclusion that anywhere from 44,000 to 98,000 people die each year as a result of medical errors caused largely by failures or glitches in systems of care.

Ventura County Star (Ventura County, Ca.)
March 14, 2000, Tuesday
Patients' safety needs to become top priority
MEDICAL ERRORS: Two studies reveal shocking statistics relating to deaths in hospitals.

Most of us have heard at least one shocking story about medical errors -- the 8-year-old boy who died because of a drug mix-up during minor surgery, the health reporter who died of an accidental overdose of chemotherapy drugs, the man whose healthy leg was amputated by mistake.
In the past, these cases were considered isolated incidents. However, a look at the numbers reveals they are anything but. Based on the findings of one major study, 44,000 hospital patients die each year as a result of medical errors. Another study puts the number higher -- at 98,000. Even using the conservative estimate, more Americans die each year from medical mistakes than from traffic accidents, breast cancer or AIDS. And while errors may be more easily detected in hospitals, they afflict just about every health-care setting -- from retail pharmacies to outpatient clinics to nursing homes.

PR Newswire
March 13, 2000, Monday
How Safe Is Anesthesia? The Answer May Surprise You... New Technology Improves Patient Care During and After Surgery;
For more information on this report or to preview the video go to: http://www.healthanswers.com/video/media/splash.asp
The problem of medical errors has been in the headlines recently, with the President and Congress focused on reducing errors by 50 percent in the next five years. This is no small task, as reported in a recent Institute of Medicine report, which estimated that medical errors cause 44,000 to 98,000 deaths per year. But the report also called out that one of the most feared components of surgery, anesthesia, is one of the safest. Anesthesiologists have led the effort to improve patient safety. Recent advances in their practice provide benefits not only in the operating room but in the post-operative setting, as well.

PR NEWSWIRE
March 13, 2000
How Safe Is Anesthesia? The Answer May Surprise You... New Technology Improves Patient Care During and After Surgery

For more information on this report or to preview the video go to: http:/ /www.healthanswers.com/video/media/splash.asp
NEW YORK, March 13 /PRNewswire/ -- The problem of medical errors has been in the headlines recently, with the President and Congress focused on reducing errors by 50 percent in the next five years. This is no small task, as reported in a recent Institute of Medicine report, which estimated that medical errors cause 44,000 to 98,000 deaths per year. But the report also called out that one of the most feared components of surgery, anesthesia, is one of the safest. Anesthesiologists have led the effort to improve patient safety. Recent advances in their practice provide benefits not only in the operating room but in the post-operative setting, as well. Facts About Anesthesia: -- Seventeen million patients undergo surgery with general anesthesia each year. -- Since the early 1980s, injuries and deaths from anesthesia have dropped from 1 in 10,000 to 1 in 250,000, mainly due to new processes, drugs and technologies. -- The latest technology in anesthesia is the Bispectral Index(R) (BIS(R), pronounced "biz") monitor, a powerful tool that measures the impact of anesthetic dosing. -- BIS monitoring directly measures how awake or asleep a patient is during surgery, providing anesthesiologists with valuable information that enables them to better customize the amount of anesthesia each person receives. -- Experts agree that patients can reduce their anxiety about anesthesia and help improve their chances for a smooth recovery by talking with their anesthesiologist about questions or concerns, any medications they are taking, different anesthesia options and new drugs and technology that help speed recovery.

CNN
SHOW: CNN NEWSSTAND 22:00
March 11, 2000; Saturday
Medical Mistakes Put Laboratories Under the Microscope; Arizona Holds Online Primary; Sex Sells, But Why is America Still Buying?
LEAD:
THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
ANNOUNCER: It's Friday, March 10, 2000.
Tonight on CNN NEWSSTAND: A family says their little boy died because of what a lab test didn't find.
(BEGIN VIDEO CLIP)
KYRA PHILLIPS, CNN CORRESPONDENT: This is a $15 test.

Knight Ridder/Tribune News Service
San Jose Mercury News
March 10, 2000, Friday
Rx: Reduce mistakes _ Clinton's goal is laudable, and hospitals certainly can learnfrom other industries
The following editorial appeared in the San Jose Mercury News on Wednesday, 3-8:
An airliner doesn't fall out of the sky every day in the United States. Tens of thousands of checks are not deducted daily from the wrong accounts at the bank. But every day, thousands of errors in hospitals and clinics lead to injury or death for patients.
Up to 98,000 Americans die each year from medical mistakes, the Institute of Medicine estimated in a report last year. Even a more conservative estimate of 44,000 deaths a year would still rank medical errors as the eighth-leading cause of death in the United States.

Federal Document Clearing House Congressional Testimony
March 9, 2000, Thursday
TESTIMONY March 07, 2000 WILLIAM L. ROPER, MD DEAN OF SCHOOL ASSOCIATION FOR HEALTH SERVICES RESEARCH HOUSE APPROPRIATIONS LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION LABOR HHS APPROPS
STATEMENT OF THE ASSOCIATION FOR HEALTH SERVICES RESEARCH WILLIAM L. ROPER, M.D., MPH MARCH 7, 2000 Thank you, Mr. Chairman and Members of the House Appropriations- Labor,- Health and Human Services, Education and Related Agencies Subcommittee, for the opportunity to present testimony on the critical role of health services research in improving our nation's health care. My name is William L. Roper, M.D., MPH, and I am Dean of the School of Public Health at the University of North Carolina at Chapel Hill (UNC). Prior to UNC, I served as Administrator for the Health Care Financing Administration from 1986- 1989 and as Director for the Centers for Disease Control and Prevention from 1990-1993. Today I am representing the Association for Health Services Research (AHSR), a non-profit national professional association devoted to improving the health status of Americans through health services research. AHSR represents more than 2,800 individuals and 130 organizational members, including universities, insurers, providers, employers, and health plans that use and produce health services research information. I serve on the Board of the Association and was its President in 1996-1997. 1 particularly want to thank the Subcommittee for its efforts over the past few years in support of federal funding for health services research. Health services research results are increasingly being utilized by every segment of the health care delivery system to improve care, expand access, and reduce costs. As a result, the need for increased funding for health services research has never been more imperative than now.

BANGOR DAILY NEWS (BANGOR, MAINE)
March 7, 2000 Tuesday
Too many errors in medicine "Lord, deliver me from the man who never makes a mistake, and also from the man who makes the same mistake twice. " -- Dr. William Mayo
The practice of medicine is replete with opportunities to make deadly errors and this was one of them.
The patient needed 10 units of insulin; instead, the doctor gave the patient 10 cc'sof insulin, 100 times the correct dose. The patient was lucky, suffering nothing but the constant company of the anxious doctor for the rest of the night as he pushed ampules of glucose into the patient's IV to prevent a potentially fatal insulin reaction.

Business Wire
March 6, 2000, Monday
Surgical Safety Products Inc. and IBM Announce Plans to Deploy OASiS
Surgical Safety Products, Inc. (OTCBB:SURG), a business-to-business healthcare internetworking company, announced that IBM Global Services will lead the nationwide deployment of SURG's OASiS Touch-Access(tm) information system. OASiS is an Internet-based information network that makes essential medical information readily available to hospital staff, healthcare professionals, and others instrumental to patient care.
SURG has signed IBM Global Services' e-business team to provide technology, asset services, web hosting, and support services for this information access system. IBM will have responsibility for services ranging from the original site survey prior to installation through 24 x 7 support service as the network builds its nationwide presence.

Drug Topics
March 6, 2000
Voluntary reporting, confidentiality seen as key to preventing errors.
It's important to maintain the voluntary reporting of drug errors and the confidentiality of the drug-error reporters, emphasized one of the speakers at the 2000 Technical Conference held by the American Health Quality Association (AHQA) in Orlando, Fla., last month.
Judy Smetzer, director of risk management services with the Institute for Safe Medication Practices (ISMP), underscored the importance of a voluntary, nonpunitive program. In a voluntary system, more health-care providers and pharmacists will report problems, she said. This will promote more understanding of factors leading to errors. In addition, a mandatory system will not increase patient safety or the public's trust in the health-care system, "since fear of reprisal will drive errors further underground," she said. At recent Congressional hearings, she added, a mandatory program was criticized by "almost everyone."

TELEGRAM & GAZETTE
March 06, 2000 Monday, ALL EDITIONS
Medical mistakes;
Hospitals search for ways to minimize human error
May we have your autograph?
You don't have to be a Red Sox pitcher or the governor to be asked for your signature at UMass Memorial Health Care.
But instead of putting your John Hancock on paper, surgery patients, while in the pre-operative holding area, are being asked to take a Magic Marker, and, in indelible ink, initial the site- say, left knee or right knee- that's going under the knife. If you don't want to do it, a member of the surgical team will sign for you.
We make sure that the operative consent matches the operative schedule and coincides with the medical history and physical exam,'' said Mary Camosse, a pari-operative clinical educator at UMass Memorial. If everything doesn't correspond, we call the surgeon and have him come down and address the issue.''

Morbidity and Mortality Weekly Report
March 3, 2000
Monitoring Hospital-Acquired Infections to Promote Patient Safety -- United States, 1990-1999.
Hospital-acquired infections are adverse patient events that affect approximately 2 million persons annually [1]. National Nosocomial Infections Surveillance (NNIS) is a voluntary, hospital-based reporting system established to monitor hospital-acquired infections and to guide the prevention efforts of infection control practitioners (ICPs). The NNIS approach may be a model for future programs aimed at preventing other adverse patient events [2]. This report describes the decrease in infection rates reported in NNIS hospitals during 1990-1999, presents the results of a survey of ICP responsibilities, and discusses the importance of NNIS for monitoring adverse patient events.
NNIS began in 1970 with 62 participating hospitals in 31 states. In 1999,285 hospitals in 42 states participated in NNIS [1]. All NNIS hospitals have [greater than or equal to] 100 beds and tend to be larger than other U.S. hospitals (median size: 360 beds versus 210 beds); however, both NNIS and non-NNIS hospitals have a similar geographic distribution. The purposes of NNIS are to establish national risk-adjusted benchmarks for hospital-acquired infection rates and for device use ratios [3] by using uniform case definitions and data collection methods and computerized data entry and analysis. To promote the use of standardized data collection and analysis methods, ICPs receive 28 hours of training at CDC and are invited to attend a biennial conference.

THE HARTFORD COURANT
March 2, 2000 Thursday, STATEWIDE
SHOULD DATA ON TROUBLED DOCTORS BE AVAILABLE TO PUBLIC?;
OFFICIALS ARE DEBATING WHETHER TO OPEN A FEDERAL DATA BANK THAT CONTAINS RECORDS OF THOUSANDS OF DOCTORS WHO HAVE BEEN DISCIPLINED FOR MALPRACTICE AND OTHER MISDEEDS.
Two days after delivering a baby daughter by emergency caesarean section last year, Liana Gedz, a 31-year-old New York City dentist, was shocked to discover that her doctor had carved his initials, A.Z., onto her abdomen.
"I truly believe that we have a white wall of silence: Hospitals protect doctors, doctors protect their peers, and in all of this, crucial information is getting lost," Gedz said Wednesday as she urged Congress to open a federal data bank that contains the records of thousands of doctors who have been disciplined for malpractice and other misdeeds.

BioPharm
March 1, 2000
Medication Errors Draw Congressional Scrutiny : Manufacturers won some important policy changes in Washington last year but now face a high-profile debate on medical safety.
Despite the stalemate on Capitol Hill last year, the 106th Congress did adopt a number of measures that are important for the biotechnology industry. A key victory was reauthorization of the research and experimentation (R&E) tax credit for five years, instead of the usual one-year extension, as part of a minor tax bill. To ensure final approval, the $ 21 billion tax measure was attached to a popular bill that encourages disabled individuals to return to work by permitting them to retain subsidized health insurance while employed (1).
Biomedical research continued to gain support from legislators as Congress approved a significant increase in funding for the National Institutes of Health (NIH) (2). The agency won a $ 17.9 billion budget, up by $ 2.3 billion as part of the continuing campaign to double its total budget by 2004. The NIH Human Genome Project and Center for Alternative Medicines realized big gains, as did gene sequencing and biocomputing projects.

Employee Benefit News
March 01, 2000
Top employers vow improvements to system
Karen Lee
Although new research suggests considerable support for employment-based health benefits, executives from some of the nation's largest companies are pointing toward new solutions for problems that threaten to undermine consumer confidence.
Support for employer-sponsored benefits has come into question following studies indicating a desire for change might be brewing. For example, a survey released last year by KPMG Market Research found that 73% of 14,626 employees at 117 of the nation's largest corporations would be interested in a defined contribution health benefits system similar to the approach used for many retirement plans.
But according to a recent study by The Commonwealth Fund, a private foundation that supports independent research of health and social issues, two-thirds of the country's 155 million working-age people have employer-provided health care, and three-quarters of those say their employers do a good job selecting the plans.

Federal News Service
March 1, 2000, Wednesday
PREPARED TESTIMONY OF THE HONORABLE FRED UPTON
BEFORE THE HOUSE COMMERCE COMMITTEE SUBCOMMITTEE ON OVERSIGHT & INVESTIGATIONS
SUBJECT - PUBLIC ACCESS TO THE NATIONAL PRACTITIONER DATA BANK: WHAT CONSUMERS SHOULD KNOW ABOUT THEIR DOCTORS.
Welcome to today's hearing of the Oversight and Investigations Subcommittee on the issue of whether or not the National Practitioner Data Bank should be open to the general public. I want to thank all of our witnesses for agreeing to appear before us today and offer their perspectives on this important and timely issue.
We are going to hear from four individuals today who have had horrific experiences with our health care system as a consequence of their physicians' incompetence or misconduct. No health care system-and particularly one that is touted as offering the most sophisticated, finest quality of care in the world-should tolerate such conduct or permit such incompetence. We need to ask some very hard questions this morning. How did our system fail to weed out these doctors? Did the states that licensed them thoroughly investigate them when they applied for licenses? Did the hospitals where they practiced have effective, stringent peer review programs in place and query the Data Bank as required by law? Do we have all of the tools necessary at the state and federal level to protect patients from incompetent and even criminal doctors?

Ladies Home Journal
March 1, 2000
When Doctors Make MISTAKES; recommendations that may help prevent medical errors
Every year, tens of thousands of patients in the United States die as a result of medical errors. Here, how to protect yourself and your family
What Patsy McDonald most clearly recalls about the 1997 accident is her sport-utility vehicle (SUV) rolling over into a ditch. Patsy emerged unscathed. Her daughters, Sally, nine, and Kelsey, eight, weren't so lucky. The SUV had slammed into a fence post, hitting Kelsey in the left arm and chest and striking Sally's face. A Medevac helicopter flew Kelsey to a nearby university hospital; Sally, whose injuries appeared less life-threatening, was taken by ambulance.
Kelsey's left arm was fractured; a large chunk of wood from the fence post was lodged in her chest. Sally suffered a collapsed lung and severe damage to her mouth.

Medical Marketing & Media
March 1, 2000
Senate committee warned on medical error legislation; Brief Article; Statistical Data Included
* The healthcare establishment testified before hearings held by the Senate Committee on Health, Education, Labor and Pensions and cautioned against premature legislation to solve the problem of medication and other medical errors.
The hearings were held following the release of an Institute of Medicine (IOM) report derailing the extent of serious errors.

Nursing
March 1, 2000
To err is human; to prevent, divine.
Medical errors cause between 44,000 and 98,000 deaths each year and add $ 29 billion to Americans' medical bills, according to a recent report by the Institute of Medicine (IOM). More people die from medical errors than highway fatalities.

Nursing Economics
March 1, 2000
Leadership Roundtable.
The Not-So-New Nursing Shortage Story
The current nurse shortage is expected to get worse because "RN job opportunities are expected to grow 21% over the next ten years." Added to this, nurse supply is expected to dwindle because of the rapidly aging nurse workforce with "about half of the nation's nurses expected to retire within the next 15 years."
It is suggested in this Modern Healthcare commentary that recruitment and retention programs should include a focus on candidate sources, a customer-oriented interview and selection process, a referral incentives program that attracts the best candidates, and Internet-based application options along with an effective applicant tracking process.
The organization-specific strategies put forward by members of the health care practice of Deloitte Consulting include the following:
* Focus on establishing a great organizational reputation for clinical excellence with optimum working conditions for nurses.
* Invest in strong management and quality leadership exemplified by leaders who are effective communicators and involve the staff in meaningful decisions.

Urology Times
March 1, 2000
To err is human. . . unless you're a physician.
When she was a medical resident, Felitia Froe, MD, witnessed a medical error that "was bad enough that it has tainted my thinking."
"One woman received insulin instead of heparin and subsequently died," said the Kansas City, MO urologist. "It was a nursing error, and I think that it can happen a lot. I've also seen drugs given in OR that were expired."
When the Institute of Medicine released a report in December stating that somewhere between 44,000 and 98,000 Americans die as a result of medical mistakes every year, Dr. Froe said, "My gut reaction was that it didn't surprise me. If I sit back and think about it, [the number] might be that high."

Urology Times
March 1, 2000
How the Institute arrived at its findings.
Reducing one of the nation's leading cause of death and injury-medical errors-will require rigorous changes throughout the health care system, according to a report issued by the Washington-based Institute of Medicine.
Based on the Institute's findings, medical errors are responsible for more than 44,000 deaths and as many as 98,000 deaths in U.S. hospitals every year.

The Florida Times-Union (Jacksonville, FL)
February 28, 2000 Monday, City Edition
Measuring success;
Jacksonville doctor's innovative dosage system for children may help reduce errors
A doctor in Jacksonville has helped develop a new medicine dosage system for children that is receiving national attention, thanks to the hospital industry's new focus on preventing errors in treatment.
Robert Luten, a University of Florida professor of pediatric emergency medicine who works in the emergency department of Shands Jacksonville, says the system quickly and accurately determines how much medicine to give a child.
Most medications have one dose for all adults, but there is no standard dose for children. Their dosage varies with their weight and must be recalculated as they grow.

Charleston Daily Mail
February 25, 2000, Friday
Hospital officials discuss Clinton's medical proposal
DAILY MAIL HEALTH REPORTER
Medical errors result in as many as 98,000 deaths a year in U.S. hospitals yet most hospitals, including Charleston Area Medical Center, already have systems in place to evaluate and improve patient safety.
But only 21 states, including West Virginia, require hospitals to report medical errors to some authority.
After President Bill Clinton this week called for mandatory reporting of preventable medical errors that cause death or serious injury, the topic drew debate among CAMC trustees.
Congress now will consider Clinton's proposal.

Copley News Service
February 25, 2000, Friday
Learn, don't hide, from errors
President Bill Clinton's controversial mandate that all hospitals systematically report serious and fatal medical mistakes is a bold and necessary step toward reducing the number of patient deaths from medical errors, estimated at between 44,000 and 98,000 a year.
Disappointingly, but not surprisingly, the American Medical Association and the American Hospital Association adamantly oppose mandatory reporting. They argue it would expose their members to more lawsuits, which will only make doctors and hospital workers even less inclined to speak up when mistakes occur.

Las Vegas Review-Journal (Las Vegas, NV)
February 25, 2000 Friday FINAL EDITION
EDITORIAL: Mistaken proposal?
Watch out: The Clinton administration has unearthed a new medical 'crisis' and wants to create a federal regulatory agency to solve it.
A November report by the National Academy of Science's Institute of Medicine estimated that between 44,000 and 98,000 deaths a year are caused by 'medical errors' made by doctors and nurses _ mistakes that range from administering the wrong drugs to operating on the wrong body part or the wrong patient. President Clinton believes that the number of accidental deaths can be cut in half within five years by forcing hospitals to report all errors that cause serious injury or death to a new federal Center for Quality Improvement and Patient Safety.

Press Journal (Vero Beach, FL)
February 25, 2000, Friday
HOSPITAL DAMAGE DISCLOSURE

The Clinton administration has proposed a federal law requiring all hospitals in the nation to report how many people they kill and maim each year, and that, it would seem on the surface, is not such a bad idea, a means of alerting patients that going to certain hospitals may entail certain unfortunate risks.
But while there are still other reasons to recommend this sort of disclosure, the idea has its problems, including the following:
The proposal is based on questionable statistics. The Institute of Medicine has said that medical mistakes are taking the lives of 44,000 to 98,000 people a year. Statisticians will tell you that so large a margin of error makes the numbers almost meaningless.

St. Louis Post-Dispatch
February 25, 2000, Friday, FIVE STAR LIFT EDITION
LEARN, DON'T HIDE, FROM ERRORS
HEALTH CARE
PRESIDENT Bill Clinton's controversial mandate that all hospitals systematically report serious and fatal medical mistakes is a bold and necessary step toward reducing the number of patient deaths from medical errors, estimated at between 44,000 and 98,000 a year.
Disappointingly, but not surprisingly, the American Medical Association and the American Hospital Association adamantly oppose mandatory reporting. They argue it would expose their members to more lawsuits, which will only make doctors and hospital workers even less inclined to speak up when mistakes occur.

The Boston Globe
February 23, 2000, Wednesday ,THIRD EDITION
PREVENTING FATAL ERRORS
Hospitals in this country accidentally kill an estimated 44,000 to 98,000 patients every year. That is an appalling toll, and it has made the reduction of medical errors a priority for everyone from policymakers in Washington to doctors and nurses.
Yesterday, President Clinton stepped in with a comprehensive error-reduction program that reflects recommendations made last November by the prestigious Institute of Medicine. The most controversial - but also most indispensable - of the president's proposals is that the states move quickly to require hospitals to report all preventable deaths and major injuries. Such mandatory reporting - which Massachusetts and 17 other states already have - is controversial because hospitals and doctors fear it will foster more lawsuits by patients or their survivors. To address this, the administration's plan would keep the names of doctors, nurses, and patients confidential. The administration also favors voluntary reporting of less serious errors.

The Bulletin's Frontrunner
February 23, 2000
Clinton Wants Medical Errors Reported; Lawmakers Say Plan Is Short On Detail, Funds.
The AP (2/23, Gearan) reported, "President Clinton wants to require fuller accounting of deadly mistakes occurring daily in America's hospitals, but skeptical senators said Tuesday his plan lacks details and the money to make it work." Predicting bipartisan report for his plan to cut medical mistakes, Clinton said, "This is a worthy endeavor." The AP added, "At the same time, he tried to convince doctors and hospitals that reporting serious problems need not lead to more malpractice lawsuits." Clinton "wants a nationwide system to report and analyze medical mistakes, similar to the airlines' reporting program for aviation accidents and safety risks." The White House plan "follows an independent report last year that missteps by medical staff kill between 44,000 and 98,000 hospitalized Americans each year -- equivalent to a jetliner crash every day." Clinton "endorsed many of the recommendations in that report from the Institute of Medicine, including establishing a goal of reducing medical mistakes by half within five years." Clinton "also asked Congress for $20 million to set up a national clearinghouse for patient safety, as the institute recommended. The institute is part of the National Academy of Sciences, a private organization chartered by Congress to advise the government on scientific matters." The AP added, " At a joint Senate subcommittee hearing Tuesday, several lawmakers offered general endorsements for Clinton's approach but said they are confused as to how the reporting system will work and who will pay for it. For example, they noted that Clinton's proposed $20 million budget is for research, not reporting.

Chattanooga Times / Chattanooga Free Press
February 23, 2000, Wednesday
Clinton Health-Mistake Plan Questioned;
Congress Wants Details on Curbing Hospital Errors
WASHINGTON -- President Clinton wants to require fuller accounting of deadly mistakes occurring daily in America's hospitals, but skeptical senators said Tuesday his plan lacks details and the money to make it work.
"This is a worthy endeavor," Clinton said as he predicted bipartisan support for a national plan to cut medical mistakes. At the same time, he tried to convince doctors and hospitals that reporting serious problems need not lead to more malpractice lawsuits.

Chicago Sun-Times
February 23, 2000, WEDNESDAY, Late Sports Final Edition
Reporting of hospital errors urged
DATELINE: WASHINGTON
President Clinton wants to require fuller accounting of fatal mistakes in America's hospitals, but skeptical senators said Tuesday that his plan lacks details and the money to make it work.
"This is a worthy endeavor," Clinton said as he predicted bipartisan support for a national plan to reduce medical mistakes. At the same time, he tried to convince doctors and hospitals that reporting serious problems need not lead to more malpractice lawsuits.

Chicago Daily Herald
February 23, 2000, Wednesday, Cook/DuPage/Fox Valley/Lake/McHenry
Medical errors should be reported
How many patients die as a result of medical errors, and what can be done to reduce those fatal mistakes?
Three months ago, the Institute of Medicine issued a shocking report asserting that medical errors annually kill 44,000 to 98,000 Americans.
President Clinton is now following up on that report by calling for mandatory reporting of fatal medical errors. The American Hospital Association promptly took issue, its spokeswoman saying, "We need to make certain that caregivers are talking about their mistakes, but we're not opening them up to lawyers and lawsuits."

Daily Herald (Arlington Heights, IL)
February 23, 2000
Editorials; News; Editorial
Medical errors should be reported
How many patients die as a result of medical errors, and what can be done to reduce those fatal mistakes?
Three months ago, the Institute of Medicine issued a shocking report asserting that medical errors annually kill 44,000 to 98,000 Americans.
President Clinton is now following up on that report by calling for mandatory reporting of fatal medical errors. The American Hospital Association promptly took issue, its spokeswoman saying, "We need to make certain that caregivers are talking about their mistakes, but we're not opening them up to lawyers and lawsuits."

Dayton Daily News
February 23, 2000, Wednesday,
CLINTON OFFERS PROPOSAL TO CUT MEDICAL ERRORS
WASHINGTON - President Clinton wants to require fuller accounting of deadly mistakes occurring daily in America's hospitals, but skeptical senators said Tuesday his plan lacks details and the money to make it work.
''This is a worthy endeavor,'' Clinton said as he predicted bipartisan support for a national plan to cut medical mistakes. At the same time, he tried to convince doctors and hospitals that reporting serious problems need not lead to more malpractice lawsuits.

Financial Times (London)
February 23, 2000, Wednesday London Edition 1
WORLD NEWS: THE AMERICAS: Clinton scheme to cut mistakes by hospitals NEWS DIGEST
President Bill Clinton yesterday announced a programme aimed at reducing mistakes in hospitals, a move some medical groups warned could lead to a sharp increase in lawsuits against healthcare institutions.
But healthcare campaigners said more comprehensive reporting of these errors would improve patient safety and hospital accountability.

The Florida Times-Union (Jacksonville, FL)
February 23, 2000 Wednesday, City Edition
HEALTH CARE;
Safety first
Anew approach to avoiding errors in health care is rational, timely and likely to produce beneficial results.
Except in the extremely rare case of a doctor or nurse who has serious mental problems, there is no reason to assume that anyone in the field causes harm intentionally. But, as an official of the Food and Drug Administration recently said, 'Medical care is now more complex than any one individual should have to shoulder.'

THE HARTFORD COURANT
February 23, 2000 Wednesday, STATEWIDE
MEDICAL ERROR REPORTING PLAN MAY BE DOA;
LIABILITY CONCERNS, PATIENT SAFETY AIRED
President Clinton tried to persuade doctors and hospitals Tuesday that his new proposal for reporting deadly medical errors would not lead to more costly lawsuits, but neither group appeared convinced.
While many organizations praised the goal of reducing medical errors, several raised concerns that could delay legislative action needed to put the plan into effect until after Clinton leaves the White House next January.

Los Angeles Times

February 23, 2000, Wednesday, Home Edition
NATIONAL PERSPECTIVE;
HEALTH;
HOSPITALS, DOCTORS FEAR FALLOUT OF CALL FOR ERROR REPORTING
Hospital and physician organizations voiced strong concerns Tuesday about President Clinton's proposal for mandatory reporting of serious or deadly medical errors, saying it could lead to a proliferation of malpractice lawsuits and encourage "a culture of blame" in medicine.
Many hospitals and doctors fear that if they are forced to report medical errors and the information is disclosed to the public, it will become an open invitation to trial lawyers to bring lawsuits. And that in turn will cause doctors and nurses to be reluctant to report mistakes for fear of undermining the institutions they work for and their colleagues.
"Our concern is it would reinforce a culture of blaming and fear, which would totally contravene the purpose of ferreting out where medical errors are," said Maureen Sullivan, legal counsel and vice president of the California Healthcare Assn.

Newsday (New York, NY)
February 23, 2000, Wednesday NASSAU AND SUFFOLK EDITION
CURBING MEDICAL ERRORS / CLINTON URGES NATIONWIDE REPORTING PROGRAM
Mindful that tens of thousands of patients have died because of medical errors, President Bill Clinton yesterday proposed a reporting program that would require hospitals nationwide to disclose mistakes that result in the death or serious disability of patients.
The president's plan, which would need congressional approval, is strongly opposed by the American Medical Association and the American Hospital Association. Both organizations say implementing such a system at the federal level would pave the way for a flurry of medical malpractice lawsuits.

The Post and Courier (Charleston, SC)
February 23, 2000, Wednesday, POST AND COURIER EDITION
Clinton's health plan has skeptics
BY:Associated Press
WASHINGTON - President Clinton wants to require fuller accounting of deadly mistakes occurring daily in America's hospitals, but skeptical senators said Tuesday his plan lacks details and the money to make it work.
"This is a worthy endeavor," Clinton said as he predicted bipartisan support for a national plan to cut medical mistakes. At the same time, he tried to convince doctors and hospitals that reporting serious problems need not lead to more malpractice lawsuits.

The Record (Bergen County, NJ)
February 23, 2000, WEDNESDAY; ALL EDITIONS
N.J. NOT IMMUNE TO FATAL ERRORS ;
HOSPITALSFINED AT LEAST 6 TIMES
New Jersey hospitals have been disciplined for at least six patient
deaths over the past 2 1/2 years caused by the sort of medical errors
that President Clinton targeted in a nationwide address Tuesday. He
announced steps intended to cut in half a mistake rate he has likened to
a jetliner crash each day.
The deaths in New Jersey attributed to human error included a child
at Monmouth Medical Center killed by an overdose of chemotherapy and a
woman undergoing surgery at Kimball Medical Center in Lakewood who was
injected with too much fluid, a spokeswoman for the state Department of
Health and Senior Services said.
The fatal errors led to thousands of dollars in fines by the state
Health Department, which requires hospitals to report any preventable
deaths or severe injuries.
STATE: NEW JERSEY, USA (94%);

Telegraph Herald (Dubuque, IA)
February 23, 2000, Wednesday
Congress, hospitals claim Clinton plan short details, funds

Fuller accounting: The president seeks a record of fatal medical mistakes
WASHINGTON (AP) - President Clinton wants to require fuller accounting of deadly mistakes occurring daily in America's hospitals, but skeptical senators said Tuesday his plan lacks details and the money to make it work.
"This is a worthy endeavor," Clinton said as he predicted bipartisan support for a national plan to cut medical mistakes. At the same time, he tried to convince doctors and hospitals that reporting serious problems need not lead to more malpractice lawsuits.

The Times (London)
February 23, 2000, Wednesday
Clinton acts to cut hospital errors
Alarmed by thousands of deaths caused by medical errors, President Clinton introduced measures yesterday requiring hospitals to report mistakes that kill or seriously injure patients.
He was responding to studies that say between 44,000 and 98,000 deaths a year can be blamed on medical errors.

University Wire
February 23, 2000
Law hospitality
How many of us realize that medical errors cause more deaths a year than the number resulting from auto accidents, breast cancer and AIDS? The National Academy of Sciences, Institute of Medicine reported that medical errors caused 44,000 to 98,000 deaths a year.
Tuesday, President Clinton, responding to such alarming statistics, called for the nation-wide system of reporting medical errors, intending for it to be fully implemented within three years.

The Deseret News (Salt Lake City, UT)
February 22, 2000, Tuesday
SECTION: WIRE; Pg. A01
Hospitals may need to note major errors
WASHINGTON -- President Clinton wants hospitals to tell patients and the government how often they kill or seriously injure those in their care.
Hospitals nationwide would have to disclose serious and deadly mistakes if Congress adopts a White House plan developed in response to a report last year that estimated medical mix-ups kill as many as 98,000 Americans each year.
Clinton also planned Tuesday to order several new requirements that do not need congressional approval, including an immediate mandatory reporting requirement for the 500 Defense Department-administered hospitals that serve an estimated 8 million people. And the Health Care Financing Administration will require error reduction plans this year in all 6,000 hospitals that participate in Medicare.

Facts on File World News Digest
February 22, 2000
Medicine and Health:Clinton Calls for Reporting of Errors
President Clinton February 22 proposed a series of measures intended to reduce the occurrence of injuries and deaths resulting from errors in administering medical care. The president called for a nationwide, state-based system of mandatory reporting of all medical mistakes that caused serious injury or death. He also proposed funding for a new federal agency that would conduct safety research and set goals for error prevention.

Federal News Service
February 22, 2000, Tuesday
PREPARED TESTIMONY OF JOHN M. EISENBERG, M.D. DIRECTOR AGENCY FOR HEALTHCARE RESEARCH & QUALITY
BEFORE THE SENATE COMMITTEE ON APPROPRIATIONS SUBCOMMITTEE ON HEALTH, EDUCATION, AND LABOR AND COMMITTEE ON HEALTH, EDUCATION, LABOR & PENSIONS
Introduction
I am very pleased to be here today to discuss the response of the Quality Interagency Coordination (QuIC) Task Force to the recent report of the Institute of Medicine on medical errors, To Err is Human: Building a Safer Health System. The QuIC is chaired by HHS Secretary Donna E. Shalala and Labor Secretary Alexis Herman; I serve as its operating chair, and I testify today in that capacity.
President Clinton has a long-standing commitment to improving health care quality and protecting patient safety. In 1998, he created the QuIC to focus Federal efforts to improve health care quality and appointed Health and Human Services Secretary Shalala and Labor Secretary Herman as co-chairs. When the IOM report was released, the President requested that the QuIC evaluate its recommendations and provide recommendations for further action to prevent medical errors.
Later today, Secretaries Shalala and Herman will formally present the response of the QuIC to President Clinton at a White House ceremony. I would now like to submit a copy of that report - Doing What Counts for Patient Safety: Federal Action to Reduce Medical Errors and Their Impact - for the record. Before I outline its details, I would like to discuss briefly the issue of medical errors and ongoing Federal efforts to improve patient safety.

The New York Times

February 22, 2000, Tuesday, Late Edition - Final
CLINTON TO ORDER STEPS TO REDUCE MEDICAL MISTAKES
President Clinton will order all hospitals in the United States to take steps to reduce medical errors that kill tens of thousands of people each year, and he will urge states to require the reporting of such errors, administration officials said today.
At the White House on Tuesday, Mr. Clinton plans to call for a nationwide system of reporting medical errors, somewhat like the system used by airlines to report aviation safety hazards, the officials said. Rather than trying to impose a federal requirement now, he is pressuring the states to adopt reporting requirements within three years.

Scripps Howard News Service
February 22, 2000, Tuesday
Disclosing the damage hospitals do
The Clinton administration has proposed a federal law requiring all hospitals in the nation to report how many people they kill and maim each year, and that, it would seem on the surface, is not such a bad idea, a means of alerting patients that going to certain hospitals may entail certain unfortunate risks.
But while there are still other reasons to recommend this sort of disclosure, the idea has its problems, including the following:
- The proposal is based on questionable statistics. The Institute of Medicine has said that medical mistakes are taking the lives of between 44,000 and 98,000 people a year. Statisticians will tell you that so large a margin of error makes the numbers almost meaningless. It has been noted, too, that the numbers are based on extrapolations from relatively few institutions, a methodology few social scientists would embrace. There is reason to believe that hospitals are killing thousands of people each year, but more reliable research would probably lead to better legislation.

THE STRAITS TIMES (SINGAPORE)
February 22, 2000
Safety checks help US hospitals cut errors

Hospitals in the US are using new ways -- from bar-coding patients to prescribing drugs via computers -- to protect patients from medical errors
WASHINGTON -- From bar-coding patients to diluting potentially hazardous doses of medication, hospitals across the United States are devising new ways of protecting their patients from deadly medical errors.
A veterans hospital in Topeka, Kansas, tags patients with bar codes to ensure they swallow the right medicines, while in Los Angeles, hospital patients unsteady on their feet wear bright orange armbands alerting workers they need special care to prevent falls, according to a report in the online newspaper Nando Times. Doctors no longer give most medication dosages verbally in a Minneapolis hospital after a nurse heard wrongly and administered a large overdose.

The Straits Times (Singapore)
February 22, 2000, Latest Edition
Safety checks help US hospitals cut errors
Hospitals in the US are using new ways -- from bar-coding patients to prescribing drugs via computers -- to protect patients from medical errors
WASHINGTON -- From bar-coding patients to diluting potentially hazardous doses of medication, hospitals across the United States are devising new ways of protecting their patients from deadly medical errors.
A veterans hospital in Topeka, Kansas, tags patients with bar codes to ensure they swallow the right medicines, while in Los Angeles, hospital patients unsteady on their feet wear bright orange armbands alerting workers they need special care to prevent falls, according to a report in the online newspaper Nando Times. Doctors no longer give most medication dosages verbally in a Minneapolis hospital after a nurse heard wrongly and administered a large overdose.
According to a recent report by the Institute of Medicine, medical mistakes kill somewhere between 44,000 and 98,000 hospitalised Americans a year -- equivalent of a jet crashing every day of the year.

The Washington Post
February 22, 2000, Tuesday, Final Edition
Clinton Seeks Medical Error Reports; Proposal to Reduce Mistakes Includes Mandatory Disclosure, Lawsuit Shield
President Clinton will propose today that all medical errors in hospitals that result in death or serious injury be publicly reported as part of a mandatory national error prevention system, White House sources said yesterday.
The recommendation, which is controversial among health care providers, is contained in a wide-ranging administration initiative to reduce the estimated 44,000 to 98,000 hospital deaths caused each year by medical mistakes.
The plan also calls for creation of a new federal office to research and promote "patient safety," for new standards to reduce medical errors caused by similar-sounding prescription drug names, and for legislation that would allow hospitals and doctors to investigate their errors without fearing that the information would later be used in malpractice suits against them.
"The president believes we should set up a multifaceted system to eliminate preventable medical errors--that it's really overdue," said an administration official involved with the plan. While acknowledging some opposition to mandatory reporting was likely, he said the White House was confident the proposals would be popular among consumers, many health providers and businesses that pay for health care.

Drug Topics
February 21, 2000
Lawmakers seeking cure for medical mistakes; Brief Article
Congress is trying to write a prescription for medical errors, but divisions over reporting mistakes may delay treatment. To bridge the gap, two lawmakers are proposing 15 demonstration projects to test mandatory versus voluntary reporting systems. Five hospitals would be required to report medical errors confidentially to the Agency for Healthcare Research & Quality, under legislation proposed by Sens. Arlen Specter (R, Pa.) and Tom Harkin (D, Iowa). Another five institutions would be required to report errors to the patient and/or the patient's family as well as to AHRQ, part of the Department of Health & Human Services. The final five sites chosen would be encouraged to report mistakes voluntarily to AHRQ, which would keep it confidential. The Specter-Harkin bill also would offer federal grants to states to establish reporting systems. The states would have to follow guidelines on the best way to report error data developed by a public-private task force.

Modern Healthcare
February 21, 2000, Monday
Cutting costs but not quality of care
You get what you pay for, the adage goes. But when it comes to healthcare quality, you don't get what you don't pay for.
"So many healthcare organizations are concerned about cost-reduction efforts-downsizing and restructuring," says Bernard Horak, an associate professor of health services management and policy at George Washington University in Washington. "There's been an overemphasis on cost reductions to the detriment of quality and customer satisfaction."

The Post and Courier (Charleston, SC)
February 20, 2000, Sunday, SUNDAY EDITION
Nation's hospitals trying to eliminate medical mistakes
Associated Press
WASHINGTON - A Topeka, Kan., veterans hospital tags patients with bar codes to ensure they swallow the right medicines.
At a Los Angeles hospital, patients unsteady on their feet wear bright orange armbands alerting workers they need special care to prevent falls.
And in a Minneapolis health system, doctors no longer give most medication dosages verbally after a nurse heard one wrong and administered a large overdose.
Hospitals nationwide are struggling to implement new patient protections to rectify what has been health care's dirty little secret: Medical mistakes kill somewhere between 44,000 and 98,000 hospitalized Americans a year.
That body count, tallied in a recent report by the Institute of Medicine, is like a jet crashing every day of the year.

Pittsburgh Post-Gazette
February 18, 2000, Friday, SOONER EDITION
BILL TARGETS ERRORS MADE IN HOSPITALS
Saying she was "shocked" to learn that up to 98,000 Americans die each year from mistakes made by hospitals and doctors, Rep. Constance Morella, R-Md., yesterday introduced a bill aimed at encouraging hospitals to share information about their errors.
"Looking at these numbers, I see that more people die from avoidable medical mistakes each year than from highway accidents, breast cancer or AIDS," she said at a news conference announcing the bill.
Morella said virtually every other industry collects, analyzes and distributes data on accidents occurring at different companies to prevent other firms from making the same mistakes.

FDCH Political Transcripts

February 17, 2000, Saturday
TYPE: COMMITTEE HEARING
U.S. REPRESENTATIVE JERRY LEWIS (R-CA) HOLDS HEARING ON MEDICAL ISSUES; DEFENSE SUBCOMMITTEE, HOUSE APPROPRIATIONS COMMITTEE
LOCATION: WASHINGTON, D.C.U.S. REPRESENTATIVE JERRY LEWIS (R-CA), CHAIRMAN
HOUSE COMMITTEE ON APPROPRIATIONS: SUBCOMMITTEE ON DEFENSE HOLDS
HEARING ON MEDICAL ISSUES

FEBRUARY 17, 2000

SPEAKERS: U.S. REPRESENTATIVE JERRY LEWIS (R-CA), CHAIRMAN
U.S. REPRESENTATIVE C.W. BILL YOUNG (R-FL)
U.S. REPRESENTATIVE JOE SKEEN (R-NM)
U.S. REPRESENTATIVE DAVID L. HOBSON (R-OH)
U.S. REPRESENTATIVE HENRY BONILLA (R-TX)
U.S. REPRESENTATIVE GEORGE R. NETHERCUTT (R-WA)
U.S. REPRESENTATIVE ERNEST J. ISTOOK, JR. (R-OK)
U.S. REPRESENTATIVE RANDY "DUKE" CUNNINGHAM (R-CA)
U.S. REPRESENTATIVE JAY DICKEY (R-AR)
U.S. REPRESENTATIVE RODNEY P. FRELINGHUYSEN (R-NJ)

U.S. REPRESENTATIVE JOHN P. MURTHA (D-PA), RANKING MEMBER
U.S. REPRESENTATIVE NORMAN D. DICKS (D-WA)
U.S. REPRESENTATIVE MARTIN OLAV SABO (D-MN)
U.S. REPRESENTATIVE JULIAN C. DIXON (D-CA)
U.S. REPRESENTATIVE PETER J. VISCLOSKY (R-IN)
U.S. REPRESENTATIVE JAMES P. MORAN (D-VA)

RUDY DE LEON, UNDERSECRETARY OF DEFENSE FOR PERSONNEL
AND READINESS

SUSAN BAILEY, ASSISTANT SECRETARY OF DEFENSE FOR HEALTH
AFFAIRS

WILLIAM LYNN, UNDERSECRETARY OF DEFENSE, COMPTROLLER,
CHIEF FINANCIAL OFFICER

LIEUTENANT GENERAL RONALD BLANCK, ARMY SURGEON GENERAL

VICE ADMIRAL R. A. NELSON, NAVY SURGEON GENERAL

LIEUTENANT GENERAL PAUL CARLTON JR., AIR FORCE SURGEON
GENERAL

*
(JOINED IN PROGRESS)
LEWIS: ... where we have been, and just how much it's going to cost to do the job right. I do not think we can have this discussion unless the department is willing to look squarely at the veterans' medical health care system.

NOTES:
Unknown - Indicates speaker unknown.
Inaudible - Could not make out what was being said.
off mike - Indicates could not make out what was being said.

PR Newswire
February 15, 2000, Tuesday
ASRT Supports Federal Efforts to Improve Patient Safety
The nation's largest radiologic science association submitted testimony to Congress this week in support of federal efforts to improve patient safety and reduce medical errors. The American Society of Radiologic Technologists, established in 1920, represents 82,000 registered radiologic technologists -- those who perform imaging examinations and plan and deliver radiation therapy treatments.
The ASRT submitted the testimony to the Senate Health, Education and Pensions Committee; the House Health Subcommittee and the House Health and Environment Subcommittee. Each is investigating an Institute of Medicine report that estimates medical errors claim between 44,000 and 98,000 American lives a year.
"The ASRT strongly supports the IOM recommendations that Congress establish a Center for Patient Safety and the nation's medical providers set a goal to reduce medical errors by 50 percent in the next five years," according to the 5-page written testimony.
To help improve patient safety, the ASRT endorses and is pursuing the establishment of federal minimum educational and credentialing standards for those who produce medical images and deliver radiation therapy. Federal regulation will have a significant beneficial impact on the safety of patients undergoing radiologic procedures.
The IOM report, "To Err is Human," recognizes that diagnostic errors can impede patient recovery. If only 0.5 percent of the average 300 million radiologic examinations performed annually in United States was improperly performed, the consequences could be more than 4,000 defective medical images every day of the year.
"The quality of these examinations is operator dependent. Obtaining medical images is not like using a point-and-shot camera," according to the testimony.

PR NEWSWIRE
February 15, 2000
ASRT Supports Federal Efforts to Improve Patient Safety

WASHINGTON, Feb. 15 /PRNewswire/ -- The nation's largest radiologic science association submitted testimony to Congress this week in support of federal efforts to improve patient safety and reduce medical errors. The American Society of Radiologic Technologists, established in 1920, represents 82,000 registered radiologic technologists -- those who perform imaging examinations and plan and deliver radiation therapy treatments.
The ASRT submitted the testimony to the Senate Health, Education and Pensions Committee; the House Health Subcommittee and the House Health and Environment Subcommittee. Each is investigating an Institute of Medicine report that estimates medical errors claim between 44,000 and 98,000 American lives a year.

Medicine & Health
February 14, 2000
Surplus Makes Both 'Restraint,' New Programs Possible in Budget Proposal.
In the midst of the annual exercise in target practice that the February presentation of the President's budget so predictably sets in motion, it is difficult to sort out substantive questions from political theater -- especially since the two occasionally overlap. Bill Clinton's last budget was bound to be attacked as a "tax and spend" proposal, and of course as "dead on arrival." And it was.
"Fantasy," House Budget Committee Chairman John Kasich (R-OH) said flatly of the proposal. "It is amazing to me that after all these years, President Clinton still cannot resist his urge to raise taxes on the American people," said an unforgiving Ways & Means Chair Bill Archer (R-TX). "I guess bad habits really do die hard."
After seven years, this particular President was also sure to be accused of camouflaging his true intentions behind a smokescreen of cooptative strategems that would create the appearance of fiscal responsibility while covertly angling to undermine the more responsible goals of his adversaries -- to relieve the tax burden on working families and get big government off the public's back.

The Columbian (Vancouver, WA.)
February 13, 2000, Sunday
TOM'S COLUMN: DON'T HIDE COMPLAINTS FROM PUBLIC
OLYMPIA -- Making information available for public benefit is what newspapers do on a daily basis. Attempts to hide information come in many euphemisms, including "privacy" and "confidentiality." And what you don't know can hurt you.
The most recent example is House Bill 1711, a measure in the Legislature that would have kept secret complaints filed against hospitals unless complaints are the subject of investigation. Due to newspaper persistence, the complaint process will become public.

Knoxville News-Sentinel (Knoxville, TN)
February 13, 2000, Sunday
Frist working to reduce medical errors
Tennessee Sen. Bill Frist has been working on how to reduce dangerous medical errors because the issue is a high priority for him as chairman of the public health subcommittee and as the only physician in the Senate.
The Institute of Medicine of the National Academy of Sciences recently completed a study estimating that medical mistakes kill 44,000 to 98,000 persons a year, including more than 7,000 deaths from medication errors.
Frist has a dual reason for making sure the problem is reduced: His health subcommittee has an oversight role for this issue, and he likely feels a duty to help improve the performance and image of his fellow physicians. Frist still sees patients at times when he's visiting parts of Tennessee.

The Tampa Tribune
February 13, 2000, Sunday, FINAL EDITION
An amendment for victims;

Constitution Committee Chairman Charles Canady, R-Lakeland, held a hearing Thursday on a proposed amendment to the Constitution for crime victims.
The bill, sponsored by Rep. Steve Chabot, R-Ohio, enumerates rights including that victims not be excluded from public proceedings involving the accused; the right to comment prior to a plea agreement, sentencing, parole or pardon; as well as the right to seek restitution and the right to reasonable notice of a release or escape.
Twenty-nine members of Congress have signed on their support, but Canady is not a cosponsor and did not reveal whether he supports the measure.

American Health Line
February 10, 2000
MEDICAL ERRORS: HOUSE OPENS DISCUSSION OF OPTIONS
The House yesterday commenced hearings on the "high visibility" issue of medical errors, which kill an estimated 44,000-98,000 Americans each year, CongressDaily reports. Unlike the Senate, the House will move more cautiously on the subject.

Federal News Service
February 10, 2000, Thursday
PREPARED TESTIMONY OF THE AMERICAN OSTEOPATHIC ASSOCIATION AND THE AMERICAN OSTEOPATHIC HEALTHCARE ASSOCIATION
BEFORE THE HOUSE COMMITTEE ON WAYS AND MEAN SUBCOMMITTEE ON HEALTH
SUBJECT - MEDICAL ERRORS - THE INSTITUTE OF MEDICINE REPORT: "TO ERR IS HUMAN"
This statement is presented on behalf of the American Osteopathic Association (AOA) and the American Osteopathic Healthcare Association (AOHA). The AOA represents the 44,000 osteopathic physicians throughout the United States who practice medicine and are committed to ensuring the highest standards of patient care. The AOA is the national professional organization for osteopathic physicians, and is the recognized accrediting authority for colleges of osteopathic medicine, osteopathic postdoctoral training programs and osteopathic continuing medical education. The AOHA represents the nation's hospitals and health systems that deliver osteopathic healthcare or osteopathic graduate medical education. Through a for-profit subsidiary, the AOHA provides its members with access to risk management assistance, among other products and services.
Osteopathic medicine is one of two distinct branches of medical practice in the United States. While allopathic physicians (MDs) comprise the majority of the nation's physician workforce, osteopathic physicians (DOs) comprise more than five percent of the physicians who practice in the United States. Significantly, D.O.s represent more than 15 percent of the physicians practicing in communities of less than 10,000 and 18 percent of physicians serving communities of 2,500 or less.

Federal News Service
February 10, 2000, Thursday
PREPARED TESTIMONY OF THE HEALTH CARE LIABILITY ALLIANCE
BEFORE THE HOUSE COMMITTEE ON WAYS AND MEAN SUBCOMMITTEE ON HEALTH
SUBJECT - "THE PREVALENCE AND NATURE OF MEDICAL ERRORS IN THE HEALTH CARE SYSTEM AND STRATEGIES FOR REDUCTION OF ERRORS"
Executive Summary
The Institute of Medicine (IOM) Report makes a significant contribution to the efforts members of the Health Care Liability Alliance (HCLA) and others in the health care field are making to improve the quality of patient care because it recognizes that:
a. the focus should be on systems, not individuals, and that prevention of future errors is more important than retrospective faultfinding;
b. reporting of adverse events is necessary to prevent future errors; and c. reporting systems currently are not working adequately because the tort litigation system discourages reporting of errors.
Because of its concern for the effect the tort system has on the quality of care, HCLA welcomes the IOM Report. The IOM Report takes the nation a significant step forward by recognizing that the tort system is a major barrier to improving the quality of care. That underlying conclusion provides the basis for meaningful federal tort reforms.

American Health Line
February 9, 2000
MEDICAL ERRORS: NEW LEGISLATION INTRODUCED IN SENATE
Hoping to address the problem of medical mistakes, Senate Labor-HHS Appropriations subcommittee Chair Arlen Specter (R-Pa.) and ranking member Tom Harkin (D-Iowa) Tuesday introduced the Medical Error Reduction Act, CongressDaily/A.M. reports. The Institute of Medicine last year issued a study which reported that medical mistakes kill an estimated 44,000 to 98,000 American each year.

Federal News Service
February 9, 2000, Wednesday
PREPARED TESTIMONY OF DONALD BERWICK, M.D. MEMBER COMMITTEE ON THE QUALITY OF HEALTH CARE IN AMERICA INSTITUTE OF MEDICINE
BEFORE THE HOUSE COMMITTEE ON COMMERCE SUBCOMMITTEE ON HEALTH AND ENVIRONMENT AND SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS AND COMMITTEE ON VETERANS' AFFAIRS
SUBJECT - MEDICAL ERRORS: IMPROVING QUALITY OF CARE AND CONSUMER INFORMATION
Good morning, Mr. Chairman and distinguished members of the three Subcommittees.
My name is Donald M. Berwick. I am a pediatrician and President and CEO of a non-profit education and research organization called the Institute for Healthcare Improvement, and also Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School. For the past two years, I have served on the Institute of Medicine'S Committee on Quality of Care in America, which is the group that issued the report on patient safety, To Err Is Human.
The patient safety report is the first in a series. The Institute of Medicine Committee on Quality of Care in America is continuing its work, and will this year issue several further reports and recommendations on how to address serious deficiencies in the quality of care. We chose to report on improving safety first, because it seems so fundamental and urgent. I must say that I hope our future reports will get as much attention as this one has.

Federal News Service
February 9, 2000, Wednesday
PREPARED STATEMENT OF JANET HEINRICH ASSOCIATE DIRECTOR HEALTH FINANCING AND PUBLIC HEALTH ISSUES HEALTH, EDUCATION, AND HUMAN SERVICES DIVISION
BEFORE THE HOUSE COMMITTEE ON COMMERCE SUBCOMMITTEES ON HEALTH AND ENVIRONMENT AND OVERSIGHT AND INVESTIGATIONS AND SUBCOMMITTEE ON HEALTH, COMMITTEE ON VETERANS'AFFAIRS
Mr. Chairman and Committee Members:
I am pleased to have the opportunity to testify today as you consider issues related to adverse medical events in the nation's health care system. Adverse events are receiving considerable attention now as a result of the recent Institute of Medicine report on medical errors. 1 Adverse events are injuries to patients caused by medical treatment; medical errors are mistakes in medical care that may or may not lead to harm. Efforts to identify adverse events and evaluate their causes are important components of strategies to reduce harm to patients. Several of our recent reports have considered surveillance systems for medical products, particularly drugs and medical devices. For example, last week we released a report that synthesizes current research on adverse drug events (ADE). 2 We have also evaluated the Food and Drug Administration's (FDA) system for monitoring problems with medical devices. 3

Federal News Service

February 9, 2000, Wednesday
PREPARED TESTIMONY OF THE HONORABLE MICHAEL BILIRAKIS CHAIRMAN
BEFORE THE HOUSE COMMERCE COMMITTEE SUBCOMMITTEE ON HEALTH AND ENVIRONMENT OVERSIGHT AND INVESTIGATIONS SUBCOMMITTEE AND HOUSE VETERAN'S COMMITTEE HEALTH SUBCOMMITTEE
SUBJECT - MEDICAL ERRORS: IMPROVING QUALITY OF CARE AND CONSUMER INFORMATION
Good morning. I want to welcome all of our witnesses and the Members who have taken the time to join us today for this important hearing.
As Chairman of this Subcommittee, I have conducted many hearings with other subcommittees and committees. Today, however, marks my first joint hearing with the Veterans' Affairs Subcommittee on Health, on which I serve as Vice Chairman. I want to extend a special welcome to my VA Committee colleagues.

Federal News Service
February 9, 2000, Wednesday
PREPARED TESTIMONY OF THE HEALTH CARE LIABILITY ALLIANCE
BEFORE THE HOUSE COMMERCE COMMITTEE HEALTH AND ENVIRONMENT SUBCOMMITTEE, AND THE OVERSIGHT AND INVESTIGATIONS SUBCOMMITTEE AND THE HOUSE VETERANS' AFFAIRS COMMITTEE HEALTH SUBCOMMITTEE
SUBJECT - "THE FINDINGS IN A REPORT FROM THE INSTITUTE OF MEDICINE ON MEDICAL ERRORS"
Executive Summary
The Institute of Medicine (IOM) Report makes a significant contribution to the efforts members of the Health Care Liability Alliance (HCLA) and others in the health care field are making to improve the quality of patient care because it recognizes that:
a. the focus should be on systems, not individuals, and that prevention of future errors is more important than retrospective faultfinding;
b. reporting of adverse events is necessary to prevent future errors; and c. reporting systems currently are not working adequately because the tort litigation system discourages reporting of errors.
Because of its concern for the effect the tort system has on the quality of care, HCLA welcomes the IOM Report. The IOM Report takes the nation a significant step forward by recognizing that the tort system is a major barrier to improving the quality of care. That underlying conclusion provides the basis for meaningful federal tort reforms.

Federal News Service
February 9, 2000, Wednesday
PREPARED TESTIMONY OF CONGRESSWOMAN CONSTANCE A. MORELLA
BEFORE THE HOUSE COMMERCE COMMITTEE SUBCOMMITTEE ON HEALTH AND ENVIRONMENT OVERSIGHT AND INVESTIGATIONS SUBCOMMITTEE AND HOUSE VETERAN'S COMMITTEE HEALTH SUBCOMMITTEE
SUBJECT - MEDICAL ERRORS: IMPROVING QUALITY OF CARE AND CONSUMER INFORMATION
Mr. Chairman and members of the Subcommittee, thank you for the opportunity to appear before you to heed the call for Congressional leadership in response to the recent report that as many as 98,000 Americans die unnecessarily every year from medical mistakes made by physicians, pharmacists and other health care professionals.
Before I read the November 29, 1999 report from the Institute of Medicine (IOM), I knew that the human cost of medical errors was high. However, I was surprised to read that medical errors kill between 44,000 and 98,000 people in U.S. hospitals each year. The IOM report estimates that the financial costs of these preventable errors are between $17 billion and $29 billion each year. Medical errors afflict patients in a variety of health care settings, including hospitals, day-surgery and outpatient clinics, retail pharmacies, nursing homes, and even in home care. The magnitude of this loss of life is staggering because these numbers mean more people die from avoidable medical mistakes each year than from highway accidents, breast cancer, or AIDS. Yet while other areas of the U.S. economy have coordinated safety programs that collect and analyze accident trends, including those that track nuclear reactor accidents, highway crashes and airline disasters, there is no centralized system for keeping tabs on medical errors and using that information to prevent future mistakes.

National Journal's CongressDaily
February 9, 2000 10:47 am Eastern Time
am
SECTION: - HEALTH
Specter, Harkin First Out Of Gate With Medical Errors Bill
A bipartisan pair of appropriators has won the race to be first with legislation to address the high profile issue of medical mistakes. On Tuesday, Senate Labor-HHS Appropriations Subcommittee Chairman Arlen Specter, R-Pa., and ranking member Tom Harkin, D-Iowa, formally introduced the Medical Error Reduction Act.
"This is something that cries out for us to do something immediately," Harkin told a news conference on the bill--the centerpiece of which is a series of 15 demonstration programs at individual hospitals to test alternative ways to report medical mistakes.

National Journal's CongressDaily
February 9, 2000 5:52 pm Eastern Time
pm
SECTION: HEALTH
First Conference On Patients' Bill Of Rights Postponed
The eagerly anticipated first conference meeting on patients' rights legislation has been postponed until the week of Feb. 27, according to a statement released this afternoon by the office of Senate Majority Whip Nickles. Nickles, the conference chairman, said the postponement came "at the request of" Senate Health, Education, Labor and Pensions ranking member Edward Kennedy, D-Mass., who has been hospitalized since Sunday with what his staff describes as a "flu-like illness." Said a Kennedy spokesman: "He wants to be there. This is very important for Senator Kennedy." The week of Feb. 27 is the soonest both chambers will be back in town - the Senate is taking its Presidents' Day recess next week, awnd the House the week after that. Although the statement noted that "Nickles and Kennedy have directed staffs to continue to work over the recess," the postponement will likely make it more difficult for Republicans to get the bill finished by their target date of the Easter recess.

Federal Document Clearing House Congressional Testimony
February 09, 2000
TESTIMONY February 09, 2000 DR. JANET HEINRICH ASSOCIATE DIRECTOR, HEALTH FINANCING AND PUBLIC HEALTH ISSUES GENERAL ACCOUNTING OFFICE HOUSE COMMERCE MEDICAL ERRORS
Oversight Hearing Medical Errors: Improving Quality of Care and Consumer Information Joint Hearing of the Subcommittee on Health & Environment and the Subcommittee on Oversight & Investigations Prepared Statement of Dr. Janet Heinrich Associate Director, Health Financing and Public Health Issues General Accounting Office Mr. Chairman and Committee Members: I am pleased to have the opportunity to testify today as you consider issues related to adverse medical events in the nation's health care system. Adverse events are receiving considerable attention now as a result of the recent Institute of Medicine report on medical errors.(1) Adverse events are injuries to patients caused by medical treatment; medical errors are mistakes in medical care that may or may not lead to harm. Efforts to identify adverse events and evaluate their causes are important components of strategies to reduce harm to patients. Several of our recent reports have considered surveillance systems for medical products, particularly drugs and medical devices. For example, last week we released a report that synthesizes current research on adverse drug events (ADE).(2) We have also evaluated the Food and Drug Administration's (FDA) system for monitoring problems with medical devices.(3) In summary, I believe that the results of our work have important implications for addressing adverse medical events including the design of surveillance systems to detect adverse events and medical errors. First, while adverse events have been recognized as a serious problem, the full magnitude of their threat to the health of the American public is unknown.

Federal Document Clearing House Congressional Testimony
February 09, 2000
TESTIMONY February 09, 2000 DR. DONALD M. BERWICK PRESIDENT AND CHIEF EXECUTIVE OFFICER INSTITUTE OF HEALTHCARE IMPROVEMENT HOUSE COMMERCE MEDICAL ERRORS
Oversight Hearing Medical Errors: Improving Quality of Care and Consumer Information Joint Hearing of the Subcommittee on Health & Environment and the Subcommittee on Oversight & Investigations Prepared Statement of Dr. Donald M. Berwick President and Chief Executive Officer Institute of Healthcare Improvement Good morning, Mr. Chairman and distinguished members of the three Subcommittees. My name is Donald M. Berwick. I am a pediatrician and President and CEO of a non-profit education and research organization called the Institute for Healthcare Improvement, and also Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School. For the past two years, I have served on the Institute of Medicine's Committee on Quality of Care in America, which is the group that issued the report on patient safety, To Err Is Human. The patient safety report is the first in a series. The Institute of Medicine Committee on Quality of Care in America is continuing its work, and will this year issue several further reports and recommendations on how to address serious deficiencies in the quality of care. We chose to report on improving safety first, because it seems so fundamental and urgent. I must say that I hope our future reports will get as much attention as this one has. In the next few minutes, I would like to summarize the findings of the IOM Committee, and then to point out specific implications for Federal action. Our report has six key findings, First, we find that American health care is unacceptably unsafe today.

Federal Document Clearing House Congressional Testimony
February 09, 2000
TESTIMONY February 09, 2000 DONALD BERWICK, MD MEMBER COMMITTEE ON THE QUALITY OF HEALTH CARE IN AMERICA HOUSE COMMERCE MEDICAL ERRORS
MEDICAL ERRORS: IMPROVING QUALITY OF CARE AND CONSUMER INFORMATION Statement of Donald Berwick, M.D. Member Committee on the Quality of Health Care in America Institute of Medicine before the Subcommittee on Health of the Committee on Veteran's Affairs and the Subcommittee on Health and the Environment and the Subcommittee on Oversight and Investigations of the Committee on Commerce U.S. House of Representatives February 9, 2000 Good morning, Mr. Chairman and distinguished members of the three Subcommittees. My name is Donald M. Berwick. I am a pediatrician and President and CEO of a non-profit education and research organization called the Institute for Healthcare Improvement, and also Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School. For the past two years, I have served on the Institute of Medicine's Committee on Quality of Care in America, which is the group that issued the report on patient safety, To Err Is Human. The patient safety report is the first in a series. The Institute of Medicine Committee on Quality of Care in America is continuing its work, and will this year issue several further reports and recommendations on how to address serious deficiencies in the quality of care. We chose to report on improving safety first, because it seems so fundamental and urgent. I must say that I hope our future reports will get as much attention as this one has. In the next few minutes, I would like to summarize the findings of the IOM Committee, and then to point out specific implications for Federal action.

St. Petersburg Times
February 09, 2000, Wednesday
Should healthcare wear a warning label?
When a recent report singled out medical mistakes as a leading cause of death and injury in this country, the moment for serious soul-searching arrived for the health care industry.
Nov. 29, 1999, was Black Monday for American medicine.
That's the day the Institute of Medicine released its study "To Err is Human."
Researchers reported that 44,000 to 98,000 deaths in the United States each year are caused by medical mistakes. Perhaps the most chilling aspect of the report was not just that so many medical mistakes happen, but the revelation that they are "one of the nation's leading causes of death and injury."

SOUTH BEND TRIBUNE
February 8, 2000, Tuesday MICHIGAN
Report: Medical errors caused 3,500 deaths
MICHIGAN Briefs
DETROIT -- A report's findings that as many as 3,534 Michiganians were among up to 98,000 hospital patients who died last year due to medical mistakes has prompted widespread scrutiny of patient safety and how to limit tragic occurrences.
But officials say it's impossible to pinpoint just how many people are maimed or killed by hospital mistakes in Michigan, which is not among 20 states requiring hospitals to report serious mistakes.

Congressional Press Releases

February 8, 2000, Tuesday
INTRODUCTION OF MEDICAL ERROR REDUCTION ACT OF 2000
FOR IMMEDIATE RELEASE: February 8, 2000 Statement of Senator Tom Harkin (D-IA) Introduction of Medical Error Reduction Act of 2000 I am very pleased to join my friend and Chairman, Senator Specter, in the introduction of the "Medical Errors Reduction Act of 2000". [And I thank Senator Inouye for cosponsoring this important legislation.] Our bill addresses a critical problem facing America's health care system -- a problem that places millions of Americans at risk of serious injury or death every time they seek medical attention. Many of my colleagues are aware of the recently released Institute of Medicine report [To Err is Human: Building a Safer Health System] which describes a health care industry plagued with systems errors and provider mistakes. And if you are familiar with the report, then you -- like me -- discovered something I don't think a lot of people are aware of. That is that we are more likely to die from a medical mistake than from diabetes, breast cancer, or a traffic accident. The report found that deaths due to medical errors are as high as the 5th leading cause of death in this country. In fact, more people die from medical errors every year [people die from medical errors every year [98,000] than from accidents [96,000 , Pneumonia [86,000 , Diabetes [accidents [96,000], Pneumonia [86,000], Diabetes [63,000], suicide [31,000 and kidney disease [suicide [31,000] and kidney disease [25,000]. Another, more conservative estimate, has it as the 8th leading cause of death -- 44,000 deaths every year.

Congressional Press Releases

February 8, 2000, Tuesday
MEDICAL ERRORS IN MAJOR PROGRAMS
FOR IMMEDIATE RELEASE February 8, 2000 Senators Push Federal Agencies to Move More Aggressively on Medical Errors in Major Programs Lieberman, Grassley, Kerrey, Nickles send letters demanding reports from HHS, DOD, OPM, and VA on action plans WASHINGTON -- A high-ranking group of Senators have called on four key federal agencies to detail the steps they plan to take to crack down on medical errors in the main federal health programs and reduce the number of preventable deaths caused each year by mistakes. Senators Joe Lieberman (D-CT), Charles Grassley (R-IA), and Bob Kerrey (D-NE) have sent letters to the heads of the Office of Personnel Management and the Departments of Health and Human Services, Defense, and Veterans Affairs, asking how the agencies would be responding to the recommendations for mandatory reporting and other reforms made by the Institute of Medicine. The IOM s recommendations were included in a groundbreaking report indicating that between 44,000 and 98,000 Americans die each year from medical errors. We are concerned that many of the deaths and serious injuries occur in federal programs including Medicare, Medicaid, the Federal Employees Benefits program, Veterans Health, and the Department of Defense s health care program - Tricare, the Senators wrote last week. In all these programs account for almost half of the health care expenditures in the United States and cover approximately 90 million beneficiaries. Total deaths in these programs may number in the tens of thousands each year. The Senators said they were particularly concerned by a report in the New York Times indicating that federal officials have already rejected one of the key recommendations made in the IOM report - requiring hospitals to report all error-related deaths and serious injuries.

Congressional Press Releases

February 8, 2000, Tuesday
MEDICAL ERRORS IN MAJOR PROGRAMS
FOR IMMEDIATE RELEASE February 8, 2000 Senators Push Federal Agencies to Move More Aggressively On Medical Errors in Major Programs Lieberman, Grassley, Kerrey, Nickles send letters asking for reports from HHS, DOD, OPM, and VA on action plans WASHINGTON - A high-ranking group of Senators have called on four key federal agencies to detail the steps they plan to take to crack down on medical errors in the main federal health programs and reduce the number of preventable deaths caused each Year by mistakes. Senators Joe Lieberman (D-CT), Chuck Grassley (R-IA), and Bob Kerrey (D-NE) have sent letters to the heads of the Office of Personnel Management and the Departments of Health and Human Services, Defense. and Veterans asking how the agencies would be responding to the recommendations for mandatory reporting and other reforms made by the Institute of Medicine. The IOM's recommendations were included in a groundbreaking report indicating that between 44,000 and 98,000 Americans die each year from medical errors. "We are concerned that many of the deaths and serious injuries occur in federal programs including Medicare, Medicaid, the Federal Employees Benefits Program, Veterans Health, and the Department of Defense s health care program - Tricare, " the Senators wrote, last week. "In all, these programs account for almost half of the health care expenditures in the United States and cover approximately 90 million beneficiaries, Total deaths in these programs May number in the tens of thousands each year. The Senators said they were particularly concerned by a report in The New York Times indicating that federal officials have already rejected one of the key recommendations made in the 10M report - requiring hospitals to report all error-related deaths and serious injuries.

INTELLIGENCER JOURNAL (LANCASTER, PA.)
February 7, 2000, Monday
Another study?;
Officials lobby against plan to require hospitals to report their medical errors
There have been some developments recently on the topic of medical errors that are worthy of note.
Anyone who cares about their continued health surely knows by now that the very reputable and very conservative Institute of Medicine of the National Academy of Science reported late last year that medical errors cause 44,000 to 98,000 unnecessary deaths a year in the United States.
This is a staggering number -- it's more carnage than encountered on American highways -- and it led the Institute to recommend that the government mandate that hospitals and doctors report their mistakes so the level and types of errors could be tracked and corrections could be made.

The Daily News of Los Angeles
February 7, 2000, Monday,
PUBLIC FORUM;
A LOT OF GALL
The Institute of Medicine released a report that states that doctors and hospitals kill 44,000 to 98,000 Americans per year by mistake.
Well, well, well, what do you think of that? Apparently American medicine is more dangerous than firearms. Firearms accidents (read mistakes) kill about 1,400 people annually. In fact, the death toll from accidents, homicides and suicides combined is lower than the low-end number killed by medical mistakes.

St. Petersburg Times
February 07, 2000, Monday, 0 South Pinellas Edition
Next hot issue: medical mistakes
Every one of us knows somebody like Gail Devers who suffered unnecessary pain as a result of having an ailment misdiagnosed and treated the wrong way.
Devers, a sprinter and hurdler and three-time Olympic gold medalist, recently shared her story with a congressional committee. Her overactive thyroid went undiagnosed for two years. Her weight fell from 130 to 87 pounds. Her hair fell out. And she thought she was losing her mind until one of her former trainers suggested she get a test for thyroid disease.

The Buffalo News
February 6, 2000, Sunday, FINAL EDITION
IN AVOIDING MEDICAL ERRORS, THE LIFE YOU SAVE MAY BE YOUR;
OWN
It chills the heart to read the Institute of Medicine's recent report on errors in health care.
It can be nothing truly surprising to anyone who works in the health care system, but the figures are arresting nonetheless: between 44,000 and 98,000 people estimated to die in hospitals each year due to medical errors.
The report, available at the institute's home page, seems to define "error" rather broadly: "The failure of a planned action to be completed as intended (i.e., error of execution), or the use of a wrong plan to achieve an aim (i.e., error of planning)." This definition leads to some second-guessing after the fact, some Monday morning quarterbacking, in examining decisions made in the heat of the moment.

The New York Times

February 3, 2000, Thursday, Late Edition - Final
Corrective Medicine;
New Technology Helps Health Care Avoid Mistakes
Every morning, Stan Pestotnik, a pharmacist, studies reports on several dozen patients at LDS Hospital, one of the nation's most technologically advanced hospitals. He zeros in on two or three who have been flagged by a computer as dangerously close to being harmed by medications they are taking.
Seriously ill patients often take 10 or 20 drugs at doses so high that vital organs can be destroyed. As soon as tests indicate deterioration, the computer issues an alert and suggests changes. Mr. Pestotnik visits the patients and consults with nurses, then telephones their doctors, typically recommending stopping a drug or reducing the dosage.

The Times-Picayune
February 3, 2000 Thursday, ORLEANS
COMPUTERS TARGETING MEDICATION MISTAKES;
HOSPITALS TRYING TO CUT PHARMACEUTICAL ERRORS
Every morning, pharmacist Stan Pestotnik studies reports on several dozen patients at LDS Hospital, one of the nation's most technologically advanced hospitals. He zeros in on two or three who have been flagged by a computer as dangerously close to being harmed by medications they are taking.
Seriously ill patients often take 10 or 20 drugs at doses so high that vital organs can be destroyed. As soon as tests indicate deterioration, the computer issues an alert and suggests changes. Pestotnik visits the patients and consults with nurses, then calls their doctors, typically recommending stopping a drug or reducing the dosage.

THE HARTFORD COURANT
February 2, 2000 Wednesday, STATEWIDE
PRESCRIPTION ERRORS PROVE COSTLY, DEADLY;
IN SENATE TESTIMONY, OFFICIALS OUTLINE LOSSES
Errors by medical professionals in administering prescription drugs cause thousands of deaths and cost billions of dollars in this country every year, federal officials told Congress Tuesday.
"Although the published estimates of drug-related deaths and injuries vary widely, all point to a national problem of very serious magnitude," said Janet Woodcock, director of the Food and Drug Administration's Center for Drug Evaluation and Research.

The State Journal-Register(Springfield, IL)
February 2, 2000 Wednesday
Reportinng can help cut medical error
WHICH OF THESE causes more deaths each year: a) motor vehicle accidents, b) AIDS c) breast cancer, d) medical errors? If you guessed a, b or c, you're wrong. Medical errors kill more Americans each year than the other three causes combined.
That's why a recent report by the National Academy of Sciences' Institute of Medicine recommends a federal law requiring hospitals to publicly report all mistakes they make that cause serious injury or death to patients.

Health Management Technology
February, 2000
Internet Solution Reduces Medical Errors
According to a recent major report released by the Institute of Medicine, between 44,000 and 98,000 Americans die each year from medical mistakes made while they are in the hospital. In particular, the report identifies medication errors as a significant contributor to this statistic. The 223-page report, To Err is Human, calls for hospitals, physicians, and healthcare organizations to implement proven safety practices and design systems geared to prevent, detect, and minimize the risks associated with medication errors. The authors of the study believe that by creating a centralized agency that mandates patient safety practices, it will be possible to achieve at least a 50 percent reduction in errors over five years.
For all healthcare providers, there are technology tools that can help decrease those incidents, improve outcomes, and reduce costs by helping to manage patients properly, preventing potential drug interaction risks, and decreasing hospitalization costs.

Medical Malpractice Law & Strategy
February 2000
Many Health Sites Violate Privacy Standards. A survey by the California HealthCare Foundation made public Feb. 1 has found that few health-oriented web sites follow their own declared standards for maintaining user confidentiality. The study found that 19 of the top 21 health sites had privacy policies, but most of these did not adhere to them. The researchers who conducted the study admitted that the operators of some of the sites may not even be aware that they are allowing too much access to information that is entered on their sites, as they do not fully understand the technological mechanisms behind the violations. Many violations involve "cookies" and banner ads, which can be used to track users' movements through the Internet and gather personal information about the users.
The Federal Trade Commission had no comment on the study, but said it plans to issue a report this spring on the status of online privacy and whether it thinks additional privacy legislation is needed. The California HealthCare Foundation stopped short of recommending new laws, observing that it conducted the survey to provide the health care industry with needed information on how to help meet site users' privacy expectations.

Newsletter-People's Medical Society
February 1, 2000
To Err Can Be Fatal.
I have mixed feelings about the recent report on medical errors in hospitals. As you probably heard, the nonprofit Institute of Medicine found that between 44,000 and 98,000 hospitalized patients die each year because of medical mistakes.
The report caused a great deal of hoopla when it was released. President Clinton called for a war on medical errors and suggested a private/public partnership to solve the problem. Sen. Edward Kennedy (D-Mass.) vowed to introduce legislation that would create a National Center for Patient Safety--something the report recommends. This will gather data on medical errors and work to correct them.

Pharmaceutical Executive
February 1, 2000
Boosting R&D, Eyeing Errors.
Congress passes a spending bill that increases budgets for medical research and considers measures to improve medication safety.
In early 1999, hopes were high that Congress would tackle a number of important health policy issues in that off-election year. However, bitter partisan sniping following the presidential impeachment battle blocked most of the critical initiatives and permitted legislators to agree on only a few measures that encourage medical research and continue coverage of certain new therapies. As Congress returns to pick up the debate about managed care reform and a Medicare prescription benefit, the hot new issue is medical safety-focusing on efforts to reduce high medication-error rates.
More for Research
Despite the general stalemate on Capitol Hill last year, the 106th Congress adopted a number of measures that are important for pharmaceutical companies, many of them wrapped up in a broad omnibus spending bill enacted just before Congress adjourned in November. Legislators approved the research and experimentation tax credit for five years-instead of the usual one-year extension-as part of a $ 21 billion tax extender bill. They also passed a measure that permits disabled individuals to retain Medicaid or Medicare coverage after they return to work.

The Progressive
February 1, 2000
Fact-Checker to the O.R.!medical errors and malpractice
You ask why I have this red and white ribbon pinned to my lapel. Well, a pink ribbon, as you know, stands for breast cancer awareness, and a solid red one signifies concern about AIDS, but I had to design this red and white one myself to call attention to the medical error epidemic.
The National Academy of Science's Institute of Medicine reported at the end of November that 44,000 to 98,000 people die every year as a result of medical errors--which beats breast cancer, AIDS, car accidents, diabetes, and pneumonia. And that's just the number of victims in hospitals. If we had good stats on the number of people killed by medical errors in other settings--nursing homes and day-surgery centers, for example--the toll would probably be right up there with lung cancer and stroke. Adding insult to grievous bodily injury, there are no criminal penalties for medical errors. Docs who poison and maim may have to pay higher malpractice insurance premiums, but they're as entitled to their fees as those who actually help.

Policy Papers
Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Report of the Quality Interagency Coordination Task Force (QuIC) To the President
February, 2000
ISSUED-BY: Quality Interagency Coordination Task Force
Quality Interagency Coordination Task Force Co-Chairs
Donna Shalala, Secretary
Department of Health and Human Services
Alexis Herman, Secretary
Department of Labor
Operating Chair
John Eisenberg, Director
Agency for Healthcare Research and Quality
Participating Departments and Agencies
Department of Commerce
Department of Defense
Department of Health and Human Services
Department of Labor
Department of Veterans Affairs
Federal Bureau of

Medical Post
February 1, 2000
Who's to blame for medical errors, MDs or the system?
TORONTO - To err may be human, but in the health-care system the human cost
of medical errors is high.
This was the emphasis for Canada's first health-care error conference held
here on Jan. 21. The conference provided a forum to address the problem of
error and adverse events in health care, and how such events ought to be
managed.
''We want to squarely face that it's there, look at its causes, minimize it
through system strategy, and deal with it openly and fairly when it
occurs,'' said Dr. Peter Singer, director of the University of Toronto
Joint Centre for Bioethics.

Modern Healthcare
January 31, 2000, Monday
Hearings look at fixes for medical errors
How hot is the medical-errors issue? So hot that last week Sen. Arlen Specter (R-Pa.) forged ahead with his second hearing on the subject despite a raging blizzard that shut down the federal government that day.
Returning to Washington last week after a two-month hibernation, lawmakers were eager to talk about how to reduce the embarrassing number of medical errors plaguing U.S. healthcare.
An Institute of Medicine report released late last year kindled Congress' intense interest (Dec. 6, 1999, p. 16). It said medical errors kill between 44,000 and 98,000 Americans each year. The IOM report urged Congress to create the National Center for Patient Safety to track errors and mandate the reporting of errors to the center.

THE PRESS-ENTERPRISE (RIVERSIDE, CA.)
January 31, 2000, Monday
EDITORIALS

The Times Union (Albany, NY)
January 31, 2000, Monday, ONE STAR EDITION
A clear way to prevent serious medical errors
Doctors' handwritings are notoriously bad. Having reviewed countless doctors' hospital and office records while I served as executive secretary for the state Board for Professional Medical Conduct for almost 14 years, I can attest to that.

The Houston Chronicle
January 28, 2000, Friday 3 STAR EDITION
OUCH;
Quiet medical error reporting would remedy health care
The National Academy of Sciences' Institute of Medicine has called for a new federal law that would require hospitals to publicly disclose all mistakes that cause patients' serious injury or death. Medical professionals, hospitals and public health officials are resisting the idea, but it deserves serious consideration if for no other reason than that better reporting of medical errors would help reduce their occurrence.

San Antonio Express-News
January 28, 2000, Friday , METRO
Medical tradition could be deadly

Congress will ignore at its peril this year the issue of what to do
about medical errors that kill people.

According to a National Academy of Sciences Institute of Medicine
study released last fall, between 44,000 and 98,000 Americans die
annually from medical mistakes, many of them preventable.

The study urged a 50 percent reduction in medical errors and asked
Congress to create a federal database in which to report them.

THE HARTFORD COURANT
January 27, 2000 Thursday, STATEWIDE
MEDICAL REPORTING RULES MAY NOT BE QUICK FIX;
CONCERNS, AND THE COMPLEXITY OF THE ISSUES, MAY DELAY LEGISLATIVE ACTION ON A PROPOSAL TO REQUIRE THE REPORTING OF DEADLY MEDICAL ERRORS BY DOCTORS AND HOSPITALS.
A federal study calling for mandatory reporting of deadly medical errors drew a skeptical response Wednesday from doctors and hospitals who said the proposal could be counterproductive and lead to a new round of costly lawsuits.
A study issued in December by the National Academy of Sciences' Institute of Medicine caused a sensation, saying that medical errors kill 44,000 to 98,000 people in U.S. hospitals each year.

Medical Industry Today
January 27, 2000, Thursday
Doctor Calls for Shorter Shifts for Health Workers
The number of medical errors made in the United States could be reduced if health workers had shorter shifts, an expert on the issue said Wednesday.
Tired workers mean that more errors will be made, Dr. Lucian Leape told the Senate Committee on Health, Education, Labor and Pensions, which is studying how to cut medical errors. For that reason, limiting the hours of medical personnel is crucial, he says.

National Journal's CongressDaily
January 27, 2000 10:48 am Eastern Time
am
SECTION: HEALTH
Speedy Legislative Fix Unlikely On Medical Error Issue
Senate legislation to respond to the Institute of Medicine's landmark report on medical errors from the lead committee of jurisdiction may not be forthcoming as quickly as some predicted when the report was issued last November.
At a Senate Health, Education, Labor and Pensions Committee hearing Wednesday, senators were carefully noncommittal about their legislative plans to address what the report said kills between 44,000 and 98,000 Americans annually.
While a bipartisan group of senators from other committees with claims to a piece of the nation's health system have announced plans to introduce a bill, HELP Chairman Jeffords "has not decided legislation is necessary," said a spokesman, adding, "He will wait and see how the hearings go."

Federal News Service
January 26, 2000, Wednesday
PREPARED TESTIMONY OF THE HEALTH CARE LIABILITY ALLIANCE
BEFORE THE SENATE HEALTH, EDUCATION, LABOR AND PENSIONS COMMITTEE
SUBJECT - "TO ERR IS HUMAN": BUILDING ON THE IOM REPORT
Executive Summary
The Institute of Medicine (IOM) Report makes a significant contribution to the efforts members of the Health Care Liability Alliance (HCLA) and others in the health care field are making to improve the quality of patient care because it recognizes that:
a. the focus should be on systems, not individuals, and that prevention of future errors is more important than retrospective faultfinding;
b. reporting of adverse events is necessary to prevent future errors; and
c. reporting systems currently are not working adequately because the tort litigation system discourages reporting of errors.
Because of its concern for the effect the tort system has on the quality of care, HCLA welcomes the IOM Report. The IOM Report takes the nation a significant step forward by recognizing that the tort system is a major barrier to improving the quality of care. That underlying conclusion provides the basis for meaningful federal tort reforms.

Federal News Service

January 26, 2000, Wednesday
HEARING OF THE SENATE HEALTH, EDUCATION, LABOR AND PENSIONS COMMITTEE
SUBJECT: INSTITUTE OF MEDICINE REPORT ON MEDICAL ERRORS
CHAIRED BY: SENATOR JAMES JEFFORDS (R-VT)

WITNESSES: GAIL DEAVERS, GOLD MEDAL OLYMPIAN, VICTIM OF MEDICAL ERROR
LUCIAN LEAPE, MEMBER, REPORT COMMITTEE, INSTITUTE OF MEDICINE
MARY FOLEY, PRESIDENT, AMERICAN NURSES ASSOCIATION
ARNOLD MILSTEIN, MEDICAL DIRECTOR, PACIFIC BUSINESS GROUP ON HEALTH
NANCY W. DICKEY, PAST PRESIDENT, AMERICAN MEDICAL ASSOCIATION
STANTON SMULLENS, CHIEF MEDICAL OFFICEER, JEFFERSON HEALTH SYSTEM
216 DIRKSEN SENATE OFFICE BUILDING, WASHINGTON, D.C.
SEN. JAMES JEFFORDS (R-VT): (In progress) -- has gained a better understanding of the problems associated with medical errors, and the recommended solutions. I anticipate the development of a bipartisan legislation, creating a health care system quality improvement framework to address these problems.
I am pleased that a number of members of the Committee, including Senators Kennedy, Frist and Dodd, have already expressed interest in joining me in that effort. I applaud the institute's efforts to highlight patient safety as a major concern in America's healthcare system. We on this Committee have been tackling issues of patient safety for a long time. Under the leadership of my colleague, Senator Bill Frist, Congress passed Senate Bill 580, the Healthcare Research and Quality Act of 1999. This newly-passed legislation reauthorized the Agency for Healthcare Policy and Research, renamed it the Agency of Healthcare Quality and Research, and refocused its mission to support healthcare research on safety and quality improvement.
The IOM report has highlighted the occurrence of medical errors in our healthcare system; a system that generally provides high quality, affordable coverage to thousands every day. Unfortunately, errors can occur at any stage of the delivery system, from prevention to diagnosis and treatment. These errors can be slight in their consequence or life-threatening.

Federal News Service

January 26, 2000, Wednesday
HEARING OF THE SENATE HEALTH, EDUCATION, LABOR AND PENSIONS COMMITTEE
SUBJECT: INSTITUTE OF MEDICINE REPORT ON MEDICAL ERRORS
CHAIRED BY: SENATOR JAMES JEFFORDS (R-VT)

Medical Industry Today
January 26, 2000, Wednesday
Call for Mandatory Reporting of Medical Errors Elicits Concern
The Institute of Medicine's recent proposal for a new federal law that would require hospitals to report serious errors reportedly is not gaining the support of federal health officials.
The officials aren't willing to back the plan at this time, citing concerns that such a requirement could inadvertently discourage reporting, according to a New York Times report.
The institute is calling for a law that would require hospitals to report all mistakes that cause serious injury or death to patients, and it also has recommended that the information on errors become available to the public, the Times reported. However, a proposal for mandatory public reporting could have unintended consequences, some federal health officials said in the report. They say that a good system of voluntary reporting may actually yield more information than a mandatory system. Doctors and hospitals are concerned that mandatory reporting could mean more lawsuits.

The San Diego Union-Tribune
January 25, 2000, Tuesday
Informed patients; Should hospitals report deaths caused by mistakes?
Which of the following causes more deaths each year: a) motor vehicle accidents, b) AIDS c) breast cancer, d) medical errors? If you guessed a, b or c, you're dead wrong. Medical errors kill more Americans each year than any of the other three causes.
That's why a recent report by the National Academy of Sciences' Institute of Medicine recommends a federal law requiring hospitals to publicly report all mistakes they make that cause serious injury or death to patients.

American Health Line
January 24, 2000
MEDICAL ERRORS: WHITE HOUSE REJECTS MANDATORY REPORTING
Federal health officials announced they have rejected a plan by the National Academy of Sciences for a new federal law requiring hospitals to report all medical mistakes, the New York Times reports. Dr. John Eisenberg, who is reviewing the proposals for the Clinton administration, stated that the White House is "generally enthusiastic about the framework" of the academy's report, but said mandatory reporting could possibly aggravate the problem. Instead, Eisenberg and other government health officials maintain that mandatory reporting could have "unintended consequences," and argued that a well-designed voluntary system would be more effective. Dr. James Bagian, director of the National Center for Patient Safety at the Department of Veterans Affairs, said, "There needs to be some level of national reporting, so we can learn from our mistakes, but to allow disclosure of hospital names and practitioners' names would be counterproductive." Regardless of the administration's response to the report, Congress is moving ahead with plans to require some form of medical error reporting. Sen. Joseph Lieberman (D-Conn.) said that the report "pushed an alarm button" and hopes to pass legislation that will reduce errors in Medicare, Medicaid, and other government health plans. "We've got to make it mandatory, but we should also protect confidentially so hospitals don't have to fear a lawsuit every time they report a preventable error," Lieberman said. But Bagian maintained, "If you're not careful here, legislation could have a chilling effect on people's willingness and ability to report errors."

The Bulletin's Frontrunner
January 24, 2000
Health Officials Object To Plan For Reporting Medical Mistakes.
The New York Times (1/24, Pear) reported, "Federal health officials say they are unwilling at this time to embrace the National Academy of Sciences' recent call for a new federal law requiring hospitals to report all mistakes that cause serious injury or death to patients. The proposal came from the academy's Institute of Medicine, which also recommended that the information on medical errors be made available to the public.

Business Insurance
January 24, 2000, Monday
Employers urged to focus on quality, not cost of plan

Federal & State Insurance Week
January 24, 2000
VIRGINIA HEALTH INSURERS & PROVIDERS UNITE ON PATIENT SAFETY.
Inspired by a report last year by the Institute of Medicine of the National Academy of Science, Virginia health insurers and provider groups have formed a coalition aimed at improving patient safety.
Virginians Improving Patient Care and Safety is made up of the Medical Society of Virginia, the Virginia Association of Health Plans, Trigon Blue Cross Blue Shield, the Virginia Hospital and Healthcare Association and the Virginia Pharmacists.
The report by the Institute of Medicine, To Err Is Human, said from 44,000 to 98,000 Americans die each year as a result of medical errors and it is time to break the "cycle of inaction" and act to improve patient safety.

Modern Healthcare
January 24, 2000, Monday
One thing leads to another ; Medical-errors report means money for medical-outcomes research
For the past three years, Aetna U.S. Healthcare has been doling out big bucks in support of outcomes-improvement research. Now, encouraged by public interest in quality improvement, it's upping the ante. This year Aetna will spend an extra $1 million for research on patient safety.
"The timing of this program is related to the Institute of Medicine announcement last month," said John Kelly, M.D., Aetna's director of physician relations. He referred to the IOM's report that 44,000 to 98,000 Americans die each year as a result of medical errors. "We see tremendous opportunity to help improve patient safety," said Kelly. "We agree with the importance the institute attaches to the issue."

The New York Times

January 24, 2000, Monday, Late Edition - Final
U.S. Health Officials Reject Plan to Report Medical Mistakes
Federal health officials say they are unwilling at this time to embrace the National Academy of Sciences' recent call for a new federal law requiring hospitals to report all mistakes that cause serious injury or death to patients.
The proposal came from the academy's Institute of Medicine, which also recommended that the information on medical errors be made available to the public.

The San Diego Union-Tribune
January 24, 2000, Monday
U.S. reluctant to tell hospitals to report errors
WASHINGTON -- Federal health officials say they are unwilling at this time to embrace the National Academy of Sciences' recent call for a federal law requiring hospitals to report all mistakes that cause serious injury or death to patients.
The proposal came from the academy's Institute of Medicine, which also recommended that the information on medical errors be made available to the public.
Some federal health officials said the proposal for mandatory public reporting could have unintended consequences and might elicit less information than a well-designed, well-run system of voluntary reporting. So far, federal health officials said, they have been unable to agree on the right mix of mandatory and voluntary reporting.

The Stuart News/Port St. Lucie News (Stuart,FL)
January 24, 2000, Monday
HEALTH OFFICIALS REJECT CARE ERROR REPORTING
WASHINGTON - Federal health officials say they are unwilling at this time to embrace the National Academy of Sciences' recent call for a new federal law requiring hospitals to report all mistakes that cause serious injury or death to patients.
The proposal came from the academy's Institute of Medicine, which also recommended that the information on medical errors be made available to the public.

THE BALTIMORE SUN
January 23, 2000, Sunday ,FINAL
Balancing costs and consumers; Uncertainty: Rate changes and a shifting market make the future murky for health-care providers.; Health care
The health industry is entering a year of increased uncertainty, with an unsettled marketplace and a major regulatory change in Maryland.
For the past few years, the industry knew the lay of the land, even if the terrain was rough.
Managed care plans dominated the insurance market, controlling costs by driving down provider reimbursements and establishing barriers to care considered unneeded or too expensive.
Impressed by the cost-trimming, governments began turning to HMOs to control Medicare and Medicaid budgets.

Chicago Sun-Times
January 23, 2000, SUNDAY, Late Sports Final Edition
Medical errors take a staggering toll in U.S.
A hospital's first requirement, wrote Florence Nightingale, is to do no harm.
But all too often, hospitals, clinics, doctors and nurses make mistakes that do grievous harm to patients.
A surgeon at Rush-Presbyterian-St. Luke's Medical Center leaves a surgical sponge in an elderly man's abdomen after gallbladder surgery. A woman recovering from back surgery at Michael Reese Hospital learns her surgeon operated on the wrong two discs. A father of three dies after receiving repeated chemotherapy overdoses at the University of Chicago Hospitals.

San Antonio Express-News
January 22, 2000, Saturday , METRO
Voluntary disclosure of medical errors urged

Health care providers should make public the medical mistakes
that kill tens of thousands of patients each year, the chairman of
the American Hospital Association said Friday.

A recent report by the Institute of Medicine, part of the National
Academy of Sciences, suggested medical errors kill 44,000 to 98,000
people a year.

While those numbers were not news to many in the health care world,
the report raised widespread public interest in reducing medical
mistakes.

The Herald-Sun (Durham, N.C.)
January 21, 2000, Friday
Medical deaths 'system errors'
Director of health care agency meets with doctors at Duke University Medical Center to discuss how to reduce problems in patient care
The man on the hot seat to propose some cures for what ails American health care was admitted to Duke University Medical Center this week - not for treatment, but for philosophical give-and-take.
John Eisenberg, director of the federal Agency for Healthcare Research and Quality, met with Duke medical and business school students and professionals Wednesday night and Thursday, exchanging ideas on how the federal government might help reduce medical errors.
In November, the National Academy of Sciences' Institute of Medicine reported that 44,000 to 98,000 people die in the nation's hospitals each year from medical errors. Even the lower number would make medical errors a virtual epidemic, the eighth leading cause of death in the nation, said Eisenberg. It would be higher than the 43,000 deaths from motor vehicle accidents or the 42,000 from breast cancer. AIDS, by contrast, kills 16,500 but receives more research funding. Still, American medicine is considered among the best in the world.

The News and Observer (Raleigh, NC)
January 21, 2000 Friday, DURHAM EDITION
Medical errors get an exam
DURHAM -- Medical care in the United States might be envied around the world, but more people die from medical errors in this country than they do from auto accidents, breast cancer or AIDS. On Thursday, about 75 people at Duke University Medical Center put their heads together with Dr. John Eisenberg, head of the federal agency addressing the problem, to figure out how to improve the track record. A report in December by the Institute of Medicine of the National Academy of Sciences said that as many as 44,000 to 98,000 people die in hospitals each year as a result of medical errors, making errors the eighth-leading cause of death, using the lower estimate. In response to the report, President Clinton directed the Agency for Healthcare Research and Quality to figure out what leads to mistakes and how to prevent them.

Dayton Daily News
January 18, 2000, Tuesday,
ERASING THE ERRORS
It took a radical change from conventional thinking for Grandview and Southview hospitals to reduce hospital-bred infections last year by installing more soap dispensers.
Instead of pointing fingers at the people who were making mistakes, the hospitals' quality improvement officials aimed their scrutiny at the process by which mistakes were made. "It was a shift from saying, 'You're a bad nurse,' to asking, 'What can we do to enable her to perform at her best?' ' says Dr. Troy Tyner, who chairs the quality improvement committee.
Patients catch infections in all hospitals. That is unavoidable in a place that houses sick people, even though people who work in hospitals invariably know they can minimize infections by washing their hands between each patient they touch.

The Richmond Times Dispatch
January 18, 2000, Tuesday, CITY EDITION
FIVE MEDICAL GROUPS FORM COALITION TO REDUCE ERRORS
Medical groups that do not always get along have formed a coalition to try to cut back on the kinds of errors that result in thousands of deaths around the country each year.
The Medical Society of Virginia, the Virginia Association of Health Plans, Trigon Blue Cross Blue Shield, the Virginia Hospital and Healthcare Association and the Virginia Pharmacists Association announced yesterday the formation of Virginians Improving Patient Care and Safety (VIPCS).

Modern Healthcare
January 17, 2000, Monday
Quality begins in the boardroom ; Trustees must remember that quality goals are just as important as financial, strategic targets
What are governing boards to make of recent events questioning the safety and quality of healthcare? Should they reassure the public and themselves that hospital care is almost always professionally provided and safe? That's true, of course, and yes, it's an important message to communicate. But boards can't stop there.
Trustees who take their responsibility to the public seriously will also seize the opportunity to re-examine how they and their hospitals have performed on quality matters. Faced with financial pressures, many boards have lost focus on quality or delegated oversight to subsidiary committees without requiring accountability for results. That's a mistake. Quality will not take care of itself, and boards have the ultimate responsibility.

THE HARTFORD COURANT
January 14, 2000 Friday, STATEWIDE
PATIENT-RIGHTS FOES PIN HOPES ON U.S. STUDY;
HMOS SAY RESEARCH INTO DEATHS CAUSED BY HOSPITALS' MEDICAL ERRORS SHOWS THAT ENACTING A PATIENTS' BILL OF RIGHTS WOULD LEAD TO LAWSUITS AND RAISE INSURANCE COSTS.
Insurers have seized on a new National Academy of Sciences study of hospital deaths in search of a new argument for why Congress should not complete work this year on legislation giving patients more clout in dealing with their health plans.
Patients' rights is one of two carryover items from the 1999 congressional agenda that have a chance of being completed before federal lawmakers adjourn for the November elections, analysts said. The other item -- a longer shot -- is the addition of a prescription drug benefit to Medicare.
\The San Francisco Examiner
January 14, 2000, Friday FIRST EDITION
Hippocratic or hypocritical oath?
STRANGE. As kids, we trusted doctors.
I'll never forget hearing my childhood doctor say, "This is it," as his
injection of adrenaline went right into my heart. He had made a 2 a.m. house call after I suffered a severe asthma attack.

THE DAILY OKLAHOMAN
January 11, 2000, Tuesday CITY EDITION
New city business joins list of few offering autopsies
You won't see advertisements for Terry Felts' business on
television or on a billboard. It wouldn't be appropriate, he
explains.
"This is something that's got a natural revulsion to it," he
concedes.
Felts plans to promote his services primarily through word of
mouth and the yellow pages.

The Denver Post
January 10, 2000 Monday 2D EDITION
Smart patients can help prevent medical mistakes Ask questions, keep records and be honest
The Institute of Medicine in Washington, D.C., estimates that 44,000 to 98,000 U.S. patients die in hospitals each year because of medical mistakes. The figure is a wide estimate because no single agency tracks medical mistakes the way accidents are logged in manufacturing, for example, or air travel.
In many cases, patients are given the wrong medicine or the wrong dose. Sometimes, doctors operate on the wrong body part. Patients can be harmed, misdirected, disabled or killed by misdiagnosis, miscommunication, bad information or neglect.

Federal & State Insurance Week
January 10, 2000
MANAGED CARE GROUP SEES SHIFT IN FOCUS AWAY FROM LIABILITY.
The head of a trade association representing the managed care industry reported last week that attitudes are changing in Congress, with the focus moving from managed care reform to the broader question of patient safety.
The impetus, President Karen Ignagni of the American Association of Health Plans said at a Jan. 5 media briefing, was a report in November by the Institute of Medicine of the National Academy of Sciences calling for Congress to create a new Center for Patient Safety charged with setting goals, funding research, tracking progress and reporting on progress.
At the same time, employers are openly beginning to talk about dropping coverage for their workers if Congress passes legislation that will raise the cost. The catalyst for that change, she said, was House passage last year of an extensive Patients' Bill of Rights.

Liability Week
January 10, 2000
MANAGED CARE GROUP SEES SHIFT IN FOCUS AWAY FROM LIABILITY.
The head of a trade association representing the managed care industry reported last week that attitudes are changing in Congress, with the focus moving from managed care reform to the broader question of patient safety.
The impetus, President Karen Ignagni of the American Association of Health Plans said at a Jan. 5 media briefing, was a report in November by The Institute of Medicine of the National Academy of Sciences calling for Congress to create a new Center for Patient Safety charged with setting goals, Funding research, tracking progress and reporting on progress.
At the same time, employers are openly beginning to talk about Dropping coverage for their workers if Congress passes legislation that will raise the cost.

Scripps Howard News Service
January 10, 2000, Monday
Suit stresses perils of medical mistakes
When John Mowatt checked into Los Robles Regional Medical Center for surgery to repair a defective artery in 1998, he knew there were some risks to the operation.
He didn't expect the medication he received during the recovery period would come close to killing him.
"It was a near death experience," Mowatt said. "It's a situation where the body rebels, and all the toxins come out through the skin. It was just terrible. Your skin flakes off and they have to treat it like open wounds."

Ventura County Star (Ventura County, Ca.)
January 10, 2000, Monday
Burton: It's time consumers had a say in health-care issues
PROCEDURES: New report is correct when it states that now is the time for major changes.

There's that gallows humor remark in which a surgeon announces that the operation was a success but the patient died. That jest was brought to mind by a report issued in November by the respected Institute of Medicine.
The New York Times reported that the document has resulted in "pressure to revamp a health-care system that calls itself the best in the world, yet hides and ignores mistakes that kill tens of thousands of patients each year."
The study, the article noted, "suggested that medical errors kill 44,000 to 98,000 people a year." Announcement of the report, entitled "To Err Is Human; Building A Better Health System," evoked responses from industry and government sources. Executives of some of the largest corporations, including General Motors and General Electric, formed "The Leapfrog Group" to spur employers to make safe medicine a top priority in health insurance for their workers. No details were reported as to how this was to be done.

Ventura County Star (Ventura County, Ca.)
January 9, 2000, Sunday
Suit stresses perils of medical mistakes
$10 MILLION: Simi Valley man says company warnings aren't sufficient.
When John Mowatt checked into Los Robles Regional Medical Center for surgery to repair a defective artery in 1998, he knew there were some risks to the operation.
He didn't expect the medication he received during the recovery period would come close to killing him.
"It was a near death experience," Mowatt said. "It's a situation where the body rebels, and all the toxins come out through the skin. E It was just terrible. Your skin flakes off and they have to treat it like open wounds."

Milwaukee Journal Sentinel
January 7, 2000, Friday Final
Project aims to cure hospitals' deadly flaws
Medical College leads study of why 'misadventures' kill thousands yearly
Hoping to prevent hundreds of accidental deaths and injuries patients suffer in hospitals each year, the Medical College of Wisconsin is spearheading an effort to study the causes of "medical misadventures."
William Hendee, a physician who is senior associate dean and college vice president, acknowledged Thursday that avoidable deaths occur in hospitals. The underlying problems continue to claim lives, he said.

The Post and Courier (Charleston, SC)
January 4, 2000, Tuesday, POST AND COURIER EDITION
LETTERS TO THE EDITOR

Chicago Tribune
January 2, 2000 Sunday, CHICAGOLAND FINAL EDITION
A WIRELESS ANSWER TO RX ERRORS;
PRESCRIPTIONS FREED OF POOR PENMANSHIP
Dr. Paul Bulow admits his penmanship isn't the greatest, but he adds his chicken scratch certainly hasn't killed anyone.
Unfortunately, a Texas cardiologist can't say the same. And, according to a recent landmark report on medical errors, other physicians, with the stroke of their pens, may be inadvertently killing patients too.

Business & Health
January 1, 2000
Washington wakes up to medical mistakes; Brief Article
Even though it contained essentially no new information, the Institute of Medicine's study on medical errors exploded on the political landscape last month like no study in recent memory. Suddenly, the need to prevent medical errors rose right up on the political health agenda with patients' rights and Medicare reform.
Using previously published studies from New York, Colorado, and Utah, the IOM, which is part of the National Academy of Sciences, estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. Even the lower figure would make medical errors the nation's eighth leading cause of death, ahead of automobile accidents, breast cancer and AIDS.

Family Practice News
January 1, 2000
Report Urges Feds to Shine Spotlight on Medical Errors; Brief Article; Statistical Data Included
WASHINGTON -- The government needs to make reporting of medical errors mandatory and establish a center for studying patient care mistakes, but errors won't be substantially reduced until doctors who err stop thinking of themselves as "sinners," according to a top expert.
"An error is a symptom of a sick system, not a sick person," Dr. Lucian L. Leape said at a press conference sponsored by the Institute of Medicine (IOM). "The question is not what to do with [the person who errs] but what can we do with the system to make sure the error doesn't happen again?"
Dr. Leape, an adjunct professor of health policy at the Harvard School of Public Health, Boston, was part of an IOM panel that wrote "To Err Is Human: Building a Safer Health System." The report, which details the high rate of errors in the U.S. health care system and recommends ways to reduce that rate, is expected to be a hot topic on Capitol Hill this year.

HealthFacts
January 1, 2000
Preventing Medical Errors: A Call to Action.
The statistics are alarming: In U.S. hospitals, between 44,000 and 98,000 people die each year due to medical errors. Even using the lower figure would make hospital medical errors the eighth leading cause of death, exceeding the number of people who die annually from highway accidents (43,458), breast cancer (42,297), or AIDS (16,516). The top figure (98,000) would move hospital errors to the country's fourth leading cause of death. As many as 3% of all hospital patients suffer injuries from treatment, half of which are preventable.
That we have a serious problem is not news. The first comprehensive study to document the prevalence of medical errors and resulting injuries was conducted by the Harvard School of Public Health and was published in 1991. What's new are the proposals for change now emanating from the National Academy of Sciences. Last month, the Academy's Institute of Medicine issued a report describing the magnitude of the problem and suggestions for improving safety.

Medical Meetings
January 1, 2000
MEDICAL ERRORS PREVENTION--CME'S ROLE.
In a recently released report that garnered an enormous amount of media attention, the Institute of Medicine (IOM) stated that between 44,000 and 98,000 people die each year in hospitals as a result of medical mistakes. That means that medical errors are the eighth leading cause of death in the U.S., responsible for more fatalities than AIDS, car accidents, or breast cancer.
Pointing out that the health care industry is more than a decade behind other high-risk industries, such as aviation, in ensuring public safety, the IOM issued a series of recommendations--one of which is of particular importance for CME providers.

Modern Physician
January 1, 2000, Saturday
Make no mistake: Errors must stop Healthcare's dirty little secret is out. And, surprisingly, the beans were spilled by the prestigious Institute of Medicine, an organization not known for being alarmist. Now patients who have been laboring under the fear that their penny-pinching HMO is likely to kill them have a more worrisome culprit: medical errors committed by their hospital, doctor or other clinicians.

The National Journal
JANUARY 1, 2000
To Err Is . . . Reason for a New Law Congress will return later this month to resume debate on a handful of already well-debated health care issues: whether to provide prescription drug benefits to Medicare beneficiaries, take steps to ensure the privacy of medical records, and boost patients' rights are just a few of them. But now a new health care headache has surfaced that promises to take center stage this year.
The issue grabbed headlines shortly after Congress left town in late November, when the Institute of Medicine released a startling report that found that medical errors kill between 44,000 and 98,000 Americans-and injure many more-each year. The report cited cases of pharmacists dispensing the wrong drugs because they misread doctors' handwriting, and of patients' medical conditions going undetected because laboratory results never reached their doctors. If the problem of medical errors were a disease, it would be the eighth-biggest killer.

Nursing Economics
January 1, 2000
Bricks and Clicks: Whither Our Customers Concerns?
WE ALL HOPE that the health care industry and your institution's Y2K disaster fears were largely unfounded and now are well behind us. One thing that isn't going away, however, is the public's heightened awareness of the hazards to be found in hospitals. The Institute of Medicine's widely publicized December 1999 research report showing that between 44,000 and 98,000 hospital patients were killed annually by "errors in patient care" received abundant media coverage that seemed to fall on highly fertile ground. A year ago the Joint Commission released some similar information that got little play in the media. So what's changed?
We're Wired
Last year 25 million Americans -- nearly 40% of all adults using the Internet -- surfed for health-related topics. Baby boomers have driven priorities in this country for several years, and, as more of them start hitting their 50s and 60s, health care information and the quality of their providers is certain to be close to the top of their lists of concerns. In their most recent publication of aggregate data, Press Ganey acknowledged that five of the top ten variables that drove patients' evaluations of their hospital care rested within the basket of concerns labeled nursing care. In addition to customer-service issues, hospital patients are going to demand access to outcome-related information about their hospitals and physicians.

Nursing Economics
January 1, 2000
Leadership Roundtable.
Guidelines? What Guidelines?
ACCORDING to a study published in the Journal of the American Medical Association, many doctors are unaware of many of the guidelines and "those who read them often fail or refuse to adopt their recommendations." This can relate to either lack of knowledge or insufficient knowledge about how to apply such guidelines or frank refusal to be influenced by such so called "cookbook" approaches. To win more acceptance among physicians of standardized guidelines, direct mailings and/or patients who are well informed about their own conditions bringing such information to their physician's can be effective. The Federal Agency for Health Care Policy and Research is compiling clinical guidelines on a Web site (www.guidelines.gov). This agency is expected to continue adding approved guidelines to this site over time.
Resource
Sherman, M. (1999, November 2). Study finds lapses on medical guidelines. New York Times, p. D10.
Bad Medicine
Maybe we've suspected that there was bad news out there on medical mistakes. The recent Institute of Medicine report quoted studies that show between "44,000 and perhaps as many as 98,000 hospitalized Americans die every year from errors."

OB GYN News
January 1, 2000
Report on Medical Errors Highlights Ailing System.
WASHINGTON -- The government needs to make reporting of medical errors mandatory and establish a center for studying patient care mistakes, but errors won't be substantially reduced until doctors who err stop thinking of themselves as "sinners," according to a top expert.
"An error is a symptom of a sick system, not a sick person," Dr. Lucian L. Leape said at a press conference sponsored by the Institute of Medicine (IOM). Dr. Leape, an adjunct professor of health policy at the Harvard School of Public Health, Boston, was part of an IOM panel that wrote "To Err Is Human: Building a Safer Health System." The report, which details the high rate of errors in the U.S. health care system and recommends ways to reduce that rate, is expected to be a hot topic on Capitol Hill this year.
Panel chair William Richardson, Ph.D., noted that anywhere from 44,000-98,000 hospitalized patients die each year as a result of medical errors. "There is a lot of opportunity to improve the situation from what it is now," said Dr. Richardson, who is also president and CEO of the W.K. Kellogg Foundation in Battle Creek, Mich.

Public Health Reports
January 1, 2000
Reducing Medical Errors Requires System Changes.
Reducing one of the nation's leading causes of injury and death--medical errors--will require rigorous changes throughout the health care system, including mandatory reporting requirements, according to the Institute of Medicine (IOM). An IOM report lays out a multifaceted strategy to reduce medical errors and calls on Congress to create a national patient safety center based at the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality).
The findings of one major study cited in the report suggest that medical errors kill some 44,000 people in US hospitals each year. Another study puts the number much higher, at 98,000. Deaths from medication errors in hospitals and other settings number more than 7000 annually

Other Years - Headlines: 1999.2000.2001.2002.2003
Other Years - Leads: 1999.2000.2001.2002.2003 (These are large files)