The National Patient Safety Foundation (NPSF) is in support of President Clinton's plan to reduce medical errors.
Dr. Henri R. Manasse, Board Chair of the NPSF, stated that NPSF supports mandatory reporting with very definite, specific provisions and caveats. If a mandatory reporting system is implemented, its primary purpose must be to learn from mistakes in order to prevent future errors. It must not be focused on punishment and blame.
"All of us in the health care community -- providers, consumers, administrators, policy makers -- are accountable. NPSF believes that the vast majority of errors result from problems in the system, not individual behavior, " he said, adding, "a punitive focus on individual providers is counterproductive and will hamper reporting and subsequent learning."
The NPSF supports mandatory reporting with the following provisions:
Accountability not blame. A system needs to be established where errors can be discussed openly. The health care system is comprised of highly trained, skilled, and committed professionals. Mistakes are part of the human condition, and solutions reside in the system. The best and the brightest can make a mistake. Mistakes need to be discussed openly and honestly to learn how to prevent them.
Independent review of reporting system information. Mandatory reporting alone will not reduce incidents and improve patient safety. Analysis of reported data must be conducted to determine the complex causes of error, so that plans for improvement can be implemented. The plans must be continually evaluated to insure improvement from the hidden, ingrained problems that are inherent in the current health care system.
"Safe Harbor" provisions to encourage health care workers to report mistakes. Health care workers must be able to discuss errors without fear of reprisal. For any reporting system to be effective, the names of individual health workers must not be released to the public or to licensing bodies. The culture of health care is rife with guilt, blame and fear, and these are the greatest obstacles to effective reporting systems.
Clear definitions for the type of mistakes to be reported. A definitive set of reporting standards needs to be established. Any proposed reporting system must include not only incidents resulting in fatality and injury but also errors that are best classified as "near hits."
In his plan, President Clinton also responded to the call for a nationwide clearinghouse on patient safety by including a proposed budget of $20 million for new medical error research and to create a clearinghouse. Since its inception, the NPSF has maintained the nation's only multi-disciplinary literature clearinghouse, covering all aspects of medical errors and patient safety. This database should serve as a model for the patient safety clearinghouse, either in its current form or modified in collaboration with other stakeholders.
The NPSF is the nation's leading voice in promoting a "new look" at errors and accidents in health care. This "new look" emphasizes accountability combined with a systems-learning approach, as opposed to existing methods that rely solely on blame and punishment. The NPSF mission emphasizes the development of a culture in health care practice that is characterized by trust, honesty, integrity and open communications for the ongoing improvement of patient safety.
The National Patient Safety Foundation is an independent, nonprofit research and education organization dedicated to the measurable improvement of patient safety in the delivery of health care. The NPSF was founded in 1997 by the American Medical Association, CNA HealthPro, 3M, and Schering-Plough Corporation. The NPSF is composed of a unique partnership of health care institutions, individual providers, product manufacturers, researchers, legal advisors, consumer advocates, regulators, and policy makers. The board of directors works collaboratively with its broad base of constituents, and the NPSF leads the patient safety movement by raising awareness, building a knowledge base, creating a forum for sharing knowledge, and facilitating the implementation of practices that improve patient safety.