Rationale for Patient Safety and Quality Improvement Act of 2005
An excerpt from Sen. Edward Kennedy’s Senate floor speech
July 21, 2005:
For even one American to die from an avoidable medical error is a
tragedy. When thousands die every year from such errors, it is a
national tragedy, and it is also a national disgrace, and an
urgent call to action.
Five years ago, the Institute of Medicine reported that medical
errors cause 98,000 deaths every year. That is an average of 268
deaths a day, every day. If errors in aviation killed 200
passengers a day in plane crashes, we would do more than simply
encourage voluntary reporting. If errors at factories caused the
deaths of 200 workers a day, we would demand more than corporate
reports. We would require real changes.
Unfortunately, the culture of medicine has an expectation of
infallibility in health professionals, and this unrealistic
assumption has been reinforced by generations of medical training
and medical practice.
When confronted with a mistake in health care, doctors and
patients and citizens often ask, “How can there be errors without
negligence?” Obviously, the fear of legal liability or
embarrassment among peers and in the press leads to strong
pressure to cover up mistakes.
In many cases, however, the inadequate design and implementation
of health systems are responsible for the problem, including
excessive work schedules and unreasonable time pressures.
We can do better. We can encourage the development of a safer
health care system. We can learn important lessons from other
dangerous fields, such as the aviation industry and the military,
which are skillful in designing ways to provide maximum feasible
The Institute of Medicine has called for strong action, and our
proposal is responding to that call. The Institute’s series of
reports on health care quality contain numerous recommendations
for improving patient safety, and if we work together, we can
make more of them a reality.
The Institute recommended that health care professionals should
be encouraged to report medical errors, without fearing that
their reports will be used against them. Our legislation
implements this sensible recommendation by establishing patient
safety organizations to analyze medical errors and recommend ways
to avoid them in the future. The legislation also creates a legal
privilege for information reported to the safety organizations,
but still guaranteeing that original records, such as patients’
charts will remain accessible to patients.
Drawing the boundaries of this privilege requires a careful
balance, and I believe the legislation has found that balance.
The bill is intended to make medical professionals feel secure in
reporting errors without fear of punishment, and it is right to
do so. But the bill tries to do so carefully, so that it does not
accidentally shield persons who have negligently or intentionally
caused harm to patients. The legislation also upholds existing
state laws on reporting patient safety information.