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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 safety.

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.

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