Learning from the successful experience of aviation industry various efforts were started towards improvement in patient safety, some of the significant measures were:
The Patient Safety Reporting System (PSRS):
A program was developed by the Department of Veterans and NASA on the lines of Aviation Safety reporting system to monitor patient safety through voluntary confidential reports.
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Organization of Peri-operative Registered Nurses (AORN), USA:
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AORN has started a voluntary near-miss events reporting system (Safety Net), covering medication or transfusion reactions, communication or consent issues, wrong patient or procedures, communication breakdown or technology malfunctions. These incident reports are analyzed and safety alerts are issued to the AORN members.
The Electronic Health Record (EHR):
Pay for performance systems link compensation to measures of work quality or goals. The 2006 Institute of Medicine report “Preventing Medication Errors” recommended alignment of profitability of hospitals, clinics, pharmacies, insurance companies, and manufacturers with the patient safety goals and incentives for safe and high quality services.
Disincentives for Preventable Medical Errors:
The Tax Relief and Health Care Act of 2006 (USA) envisaged stoppage of payments to hospitals for several negative consequences of care that result in injury, illness or death.
This rule was expected to reduce hospital payments for eight serious types of preventable incidents: Objects left in a patient during surgery, blood transfusion reactions, air embolism, falls, mediastinitis, and urinary tract infections from catheters, pressure ulcers, and sepsis from catheters. Reporting of “never events” and creation of performance benchmarks was also made mandatory for hospitals.
Encouragement for Reporting of Adverse Patient Events:
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The 1999 Institute of Medicine (IOM, USA) report recommended “a nationwide mandatory reporting system that provides for collection of standardized information by state governments about adverse events that result in death or serious harm.”
However, professional organizations, such as the Anesthesia Patient Safety Foundation, did not approve the measure apprehending that any inappropriate public disclosure and punitive action might lead to hiding the adverse events and defeat the purpose.
Although twenty three states established mandatory reporting systems for serious patient injuries or deaths by 2005, there was a lot of controversy over mandatory versus voluntary reporting.
In 2005, the US Congress passed the long-debated Patient Safety and Quality Improvement Act, 2005 establishing a federal reporting database. Under this act:
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i. The reporting of serious patient harm by hospitals is voluntary and not mandatory
ii. The reports are collected by patient safety organizations under contract to analyze errors and recommend improvements
iii. The federal government coordinates data collection and maintenance of national database
iv. The reports remain confidential and cannot be used in liability cases.
In September 2005, the National Medical Error Disclosure and Compensation (MEDC) Bill was introduced, providing physicians protection from liability and a safe environment for disclosure, as part of a program to notify and compensate patients harmed by medical errors.
By 2008, thirty five US states had statutes allowing doctors and health care providers to ‘apologize and offer expressions of regret’ without their words being used against them in courts, and seven states had also passed laws mandating written disclosure of adverse events/bad outcomes to patients/their families.