This is an edited excerpt of a Boston Globe editorial, which was published Tuesday.
FATAL errors in the health care system are often less easily identified than the mistakes that cause fatal airline crashes, but they might be better prevented if they were treated as methodically and nonjudgmentally as the latter.
A report by the Institute of Medicine of the National Academy of Sciences suggests a new approach that is attracting increasing attention. Massachusetts is one of the leaders in the effort to prevent such tragic mistakes, but it is too soon to assess the work of the Coalition for the Prevention of Medical Errors, a voluntary campaign spearheaded by the Massachusetts Hospital Association.
An initiative by the Board of Registration in Medicine has had limited success. Dr. Arnold Relman, director of the initative, says it reviews 400 cases of serious error a year, but he guesses three or four times that go unreported.
The present system stresses malpractice suits and license revocations as the ultimate sanctions against error, but these discourage physicians and other health workers from reporting mistakes.
The recommendations of the Institute of Medicine thread carefully between the malpractice model and the newer approach, which emphasizes open reporting without sanction and tries to uncover the systemic reasons for errors. The institute recognizes that some workers will have to be punished for deaths or major injuries but wants mandatory reporting for less serious mistakes.
Its most important recommendation is that the federal government get involved through the creation of a center for patient safety in the Department of Human Services that would set goals for improvements, assess progress and invest in research to upgrade standards.
The federal government contributes more than a third of the trillion-dollar national expenditure on health care. The issue of patient safety transcends state boundaries.
National oversight is appropriate to encourage the medical system, in the words of Hippocrates, to do no harm.
