Welcome to the public release of the latest Institute of Medicine report on the quality of health care in America. It has now been three years since the IOM's report To Err is Human raised public awareness of the fact that as many as 98,000 people lose their lives as a result of errors that occur in hospitals – many of which could have been prevented. In a follow-up report, Crossing the Quality Chasm, the IOM assigned much of the blame to weaknesses in the system and latent errors – errors waiting to happen. In other words, it is the system, rather than the individuals, that is the problem. 

It has become clear from these IOM reports that to make substantive changes in patient safety, we must adopt patient care information systems, such as electronic health records, as an essential component of health care delivery. Although the IOM, the National Committee on Vital and Health Statistics, and others have sounded the call for electronic health record systems, the lack of standards for how and what data are collected has been a major obstacle to their adoption in routine practice. Defining a plan to remove this obstacle was the study charge of the IOM Committee on Data Standards for Patient Safety. 

Traditionally, we have treated patient safety incidents primarily as mistakes to be investigated, much as we would investigate traffic accidents or airplane crashes. But, in health care, unlike the transportation industries, accident-prevention techniques and the necessary decision-support tools that would make safety a standard of care have not been systematically put in place. In our report, we make several recommendations to help achieve a safer health care system. 

First, if the nation wants to address patient safety comprehensively, we need to consider all lapses – not only those acts that health care providers should not have done, but also things they should have done but didn't, such as prescribing a potentially life-saving drug to an eligible patient. Up to this point the industry has focused its attention on injuries that arise from errors of commission, such as prescribing a drug to which the patient is allergic. Unfortunately, this group of errors may only be the tip of the iceberg.

Second, it is time to shift the emphasis of patient safety programs from a strategy focused on reporting injuries that have already happened to a prevention strategy aimed at providing safe and effective care from the start. The airline industry quickly moved its focus from investigations of crashes to creating procedures to prevent accidents in the future. Now, for example, pilot checklists are reviewed by crews on every flight, every day. And despite the costs, the federal government invested heavily in the computer information systems needed to protect airline passengers. It should do the same for patients and the health care system. When I flew from San Francisco to Washington yesterday, the only variable I considered was whether I would arrive on time, not whether I would arrive at all. When patients enter the doors of the health care system, they should have the same confidence that the system support is there to reduce the chances of inadvertent harm. 

The aviation industry takes great pains to ensure that the number of landings equals the number of takeoffs. Similarly, patients discharged from the hospital should have fewer medical problems, not more. The committee believes that the only way to achieve this new standard of safety is to implement patient care systems that prevent errors from occurring in the first place and enable health care providers to learn from them when they occur. 

Consequently, the committee recommends that all health care organizations implement electronic health record systems that incorporate the needs of patient safety. These electronic records should provide immediate access to complete patient information and provide decision-support tools -- such as checking for drug interactions -- that facilitate the delivery of safe care. In addition, these systems should use standardized data to capture the information necessary to help us learn from mishaps. These patient safety reports should not only cover actual harms that occurred, but also the lucky breaks or near misses, where something bad could have happened if chance or an alert health care worker had not intervened.

Currently, there are pockets of intense activity throughout the country to develop and implement these systems. But a lack of data standards and the absence of a national health information infrastructure prevent important patient information from crossing organizational and regional boundaries. Patients with chronic diseases interact with many providers, including physicians, nurses, hospitals, and pharmacies. If we want the patients' data to follow them in all settings of care, we must establish common data standards that allow electronic record systems to share information. As the single largest payer of health care expenses and the guardian of public safety, the federal government should accelerate the development and adoption of data standards by providing financial support for the development of the national health information infrastructure. 

The committee recommends that Congress authorize the Department of Health and Human Services to lead and fund a public-private partnership for the development and promotion of data standards for patient safety, with the Consolidated Health Informatics Initiative and the National Committee on Health and Vital Statistics as key partners. Our report recommends a work plan to accelerate development of data standards in the areas of common terminologies, universal methods for exchanging data among computers, and standard ways of codifying medical knowledge so that computers can provide decision support. 

Just as important as the national infrastructure is the organizational will to actively promote a culture of safety. The committee recommends that all health care organizations establish patient safety programs that maintain a constant vigil for safety incidents and near misses, and redesign their systems of care to reduce these risks. 

As much as we would like to see medical errors and injuries to patients totally eliminated, achieving the goals of patient safety will be an ongoing quest. HHS should establish a national database that collects anonymous patient information that can be used to develop new interventions to prevent errors and improve safety. This will require a standardized reporting format and uniform terminology to be effective. 

And finally, there will always be more to learn about ensuring safety. As the lead agency in the federal government for patient safety, the Agency for Healthcare Research and Quality should lead the research agenda to expand our knowledge about methods to improve patient safety, to develop better safety tools, and to maximize the impact of patient safety systems. For example, can we predict which patients are at risk for adverse events and intervene to reduce the risk? How can we involve patients and their families in methods to reduce medical errors? How can we increase use of proven treatments in chronic disease from 55 percent, where it is now, to 75 percent, and then 99 percent? Finding the answers to these questions will raise the bar for patient safety.

The committee began with a vision of an integrated clinical information system that helps clinicians deliver safer care by preventing errors. The lack of patient safety data standards prevents this vision from being realized. Our report outlines what we see as essential steps toward establishing patient safety as a new and lasting standard of care.

This concludes my opening statement. My colleagues and I would be happy to take your questions now. I'd like to remind both our listeners on the Web and those in the room to please state your name and affiliation before asking your questions. We'll begin with a question in the room.