Medical Errors Report

NCHC Writers
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Conference Addresses How to Reduce Medical Errors

Medical errors are widespread, cause millions of unnecessary injuries and tens of thousands of deaths, and most can be prevented, according to experts at a conference today in Washington, D.C., on “Best Practices: New Strategies to Reduce Medical Errors.”

Over the past year, the co-sponsors of the conference – the National Coalition on Health Care (NCHC) and the Institute for Healthcare Improvement (IHI) – have been collaborating on an effort, “Accelerating Change Today (A.C.T.) – For America’s Health,” to identify innovations that improve the quality of care, to document their impact on quality and patient safety and to disseminate that information to all parties involved in health care, including providers, purchasers and consumers. The ultimate goal is major improvement in the quality of health care. The medical errors project was headed by Dr. Lucian Leape of the Harvard School of Public Health.

Speakers at today’s conference included individuals from organizations and institutions profiled in the first A.C.T. report issued today, Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine. They described actions they have taken that could and should be adopted or adapted by the nation’s health care system and that could reduce substantially the number of medical errors that occur.

“Preventing medical errors is extremely important to improving the quality of health care and to avoiding unnecessary injury and harm,” said Henry E. Simmons, M.D., president of the National Coalition. “However, it is only one part of the much greater task we have before us and one which has been documented by numerous reports, including those of the NCHC, the Institute of Medicine, the IHI and the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry. We need to address the total problem of the overuse, underuse and misuse of health care services and to change the way medicine is practiced in this country accordingly,” he stated.

“The status quo in quality and its attendant harm and suffering is simply unacceptable,” said Donald M. Berwick, M.D. president and CEO of IHI. “We know a great deal about how to improve the quality of care, but we now need to act on that knowledge in a ‘no-fault’ environment and in every health care facility nationwide,” he added.

As part of the conference, National Coalition members — representing business, unions, providers, and consumers – discussed what their respective organizations will do to see that the information on “best practices” is both widely disseminated and implemented throughout the health care system.

Attached is a conference agenda. The A.C.T. report is available on the National Coalition Web site at or by calling 202-638-7151.

The National Coalition on Health Care is the nation’s largest, most broadly representative alliance working to improve America’s health care system. Its members include large and small businesses, unions, consumer, provider and religious groups. Its Honorary Co-Chairs are former Presidents George Bush, Jimmy Carter and Gerald R. Ford. Former Governor Robert D. Ray (R-IA) and Former Congressman Paul G. Rogers (D-FL) serve as Co-Chairs of the Coalition.

The Institute for Healthcare Improvement is an independent, non-profit education and research organization. It was founded in 1991 with the goal of fostering collaboration among health care organizations to improve the quality of health care.

Conference Agenda:

9:00 – 10:00 a.m.Henry E. Simmons, NCHC; Donald M. Berwick, IHI, and Lucian L. Leape, Harvard School of Public Health
10:00 – 10:15 a.m.Q&A;**
10:15 – 10:30 a.m.Break
10:30 – 12:10 p.m.Roger Resar, Luther-Midelfort Hospital; Gilad Kuperman, Brigham and Women’s Hospital; Steven Meisel and Caren Allivatio, Fairview Hospital; James Conway, Dana-Farber Cancer Institute, and David Gaba, VA Palo Alto Health Care System
12:10 – 12:30 p.m.John Sweeney, President, AFL-CIO
12:30 – 1:30 p.m.Q& A and Buffet Lunch
1:30 – 2:30 p.m.Ellison Pierce, Harvard Medical School; Noel Petitjean, Providence Mt. St. Vincent, and James Bagian, VHA National Center for Patient Safety
2:30 – 2:45 p.m.Q & A
2:30 – 3:30 p.m.Walter Maher, DaimlerChrysler Corporation; Morton Bahr, Communications Workers of America; David Barry, Joint Labor Management Committee of the Retail Food Industry – U.S.; Roger Bulger, Association of Academic Health Centers, and Joe Perkins, AARP
3:30 – 3:35 p.m.Margaret M. Rhoades, NCHC

Download Full Report (.pdf file)

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