Case Study
In 1999, a landmark national report called for a simple fix: make hospitals publicly disclose their serious errors, the way New York already did for cardiac surgery. Bill Clinton backed it, half the country heard about it within weeks, and then doctors, hospitals, trial lawyers, and consumer groups spent two decades fighting over the details. By 2017, researchers could show that some hospitals killed patients at thirteen times the rate of others — but the data came with one catch that made it useless to the people who needed it most.
Despite an urgent call by the prestigious Institute of Medicine in 1999 for a new disclosure system to reduce medical mistakes in hospitals, federal moves to increase transparency have been slow and contentious, and state reporting requirements have proven difficult to sustain.
In its 1999 report, the Institute, an arm of the congressionally-chartered National Academy of Sciences, concluded that between 44,000 and 98,000 patients died in the United States annually as a result of hospital errors, i.e. failures of planning or execution of medical treatment. In addition, as many as 938,000 hospital patients were injured each year by such errors. High rates of error were costly not only in deaths and injuries but also in loss of trust by patients in the health-care system, loss of morale by health-care professionals, loss of productivity by the workers who were patients, and in many other ways. In economic terms alone, estimated national costs of preventable hospital errors resulting in injury or death totaled between $17 and $29 billion a year.
Instead of new rules or stiff penalties for doctors, the Institute called on Congress and state governments to require standardized public disclosure by health-care organizations of incidents where mistakes resulted in death or serious injury. Public disclosure would hold providers accountable for serious errors, create incentives to reduce them, and inform patients’ hospital choices. The report also recommended that Congress take action to encourage voluntary and confidential reporting by doctors, nurses, and other health-care workers of less serious errors and near misses.
Response was immediate. President Bill Clinton announced that he favored national action to reduce medical errors by 50 percent in five years, as the Institute’s panel had recommended. National news reports featured the Institute’s troubling findings about the frequency of medical mistakes and officials’ commitments to take action. Weeks after the report was released, a poll taken by the Kaiser Family Foundation found that an astonishing 51 percent of respondents were aware of it.
However, conflicting interests created a political stalemate that blocked disclosure. The apparent consensus for national action splintered into battles among groups representing doctors and hospitals, public health advocates, state officials, consumer groups, and trial lawyers. When the debate got down to specifics, the American Medical Association and the American Hospital Association opposed the kind of hospital-by-hospital disclosure of serious errors that would be meaningful to consumers, although the American Nurses Association and a variety of consumer groups supported such transparency. Organizations representing health care providers argued that information about errors should have broad protection from discovery in lawsuits. On that issue they were opposed by the American Trial Lawyers Association, which sought to narrow such confidentiality. Agreement on legislation remained elusive.
These unsuccessful efforts to institute a national hospital-specific reporting system came in the wake of some limited reporting initiatives by a few states in the early 1990s. Most state hospital-specific public reporting systems reported patient outcomes (mortality rates, for example) rather than medical mistakes and focused on narrow subsets of medical procedures rather than on the comprehensive system proposed by the Institute of Medicine report. Among the strongest state systems were New York’s Cardiac Surgery Reporting System, adopted in 1989, which provided both hospital- and doctor-level information on patient outcomes for that procedure, and Pennsylvania’s requirement in 1992, which provided information regarding mortality, morbidity, and other patient treatment outcomes related to coronary artery bypass surgery.
However, most state and federal efforts continued to focus on confidential reporting or on reporting that aggregated hospital data, rather than on public disclosure of facility-specific information about medical mistakes that could help patients make informed choices and bring public pressure to bear on hospital safety. In 2005 Congress approved the Patient Safety and Quality Improvement Act, which provided a framework for voluntary reporting of medical errors by hospitals to state data centers but also established strong confidentiality requirements.
More than two decades after the Institute of Medicine’s plea for public disclosure of serious medical errors, the issue remained problematic. Medical technology made enormous advances in the early years of the 21st century. But transparency did not keep pace with technology. Accurate and complete information about the number, dynamics, and causes of errors was lacking.
In 2016, Johns Hopkins University patient safety experts examined medical death rates over eight years and concluded that more than 250,000 deaths a year resulted from avoidable medical errors, making such errors the third leading cause of death in the United States. They noted that there still was no national system for reporting such deaths.
A 2017 analysis of 22 million hospital admissions by the Boston Consulting Group in cooperation with medical experts found some hospitals had three times higher death rates and 13 times higher complication rates than others, after adjusting for age, sickness, income, and other factors. However, that information could not help patients choose safer hospitals because hospital names were kept confidential as a condition of receiving the data for analysis.
The Joint Commission for the Accreditation of Healthcare Organizations reported in 2021 that the most common mistakes were patient falls, wrong doses or types of medication, surgical errors, and misdiagnosis or delayed diagnosis of disease. In general, research suggested that patients were safer when hospitals performed a procedure frequently, had a culture of safety, and doctors and medical staff were highly skilled.
In the absence of a national transparency system to inform patients’ choices and spur improvements, federal officials, state public health authorities, employers, medical organizations, and hospitals continued to seek safety improvements and work on overall performance metrics. Federal Medicare administrators assessed annual penalties against hospitals based on readmissions and patient infections and injuries, and rated hospitals’ overall performance in a five-star Case Compare system. New York and other states required confidential reporting of harm from errors within hospitals. California required hospitals to report adverse events through a secure website. The Leapfrog Group, representing employers, introduced hospital safety ratings.
However, the United States continued to lack a reporting system that could identify and correct systemic errors in hospitals, and technology advances sometimes introduced new safety issues. The Veterans Administration inspector general reported in 2022 that early experience with a new electronic records system created errors in medications and information accuracy.
Without consistent and reliable public data, patients still could not make informed choices about hospital safety.
Updated September 2022
This case study is drawn from Full Disclosure, Fung, Graham and Weil, 2007.
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