House Joint Resolution 9 of the 2000 General Assembly Session (Appendix A), as introduced, directs the Joint Commission on Health Care (JCHC) to study the 1999 report of the Committee on Quality Health Care in America, and to examine the efficacy and appropriateness of implementing its recommendations in the Commonwealth. This resolution was not adopted by the General Assembly but was communicated via letter from the Speaker of the House of Delegates to the JCHC. The Speaker's letter, which is included in Appendix A, states:

"The House Rules Committee believes that the issues addressed by the resolution merit review. Therefore the Commission is directed to undertake the study and submit a written report of its findings and recommendations to the Governor and the 2001 Session of the General Assembly."

HJR 9 specifies that, in conducting the study, JCHC is to examine current Virginia and national data regarding adverse medical events; review current patient safety initiatives in Virginia health care practices; and develop specific recommendations for the implementation of patient safety measures in Virginia.

Based on our research and analysis during this review, we concluded the following:

• A report issued by the Institute of Medicine (IOM) in 1999 concluded that "medical errors" are a serious health problem, and estimated that as many as 44,000 to 98,000 Americans die each year as a result of preventable adverse events. The IOM concluded that medical errors occur primarily due to systemic, as opposed to individual, failures within the health care delivery system.

• The IOM issued nine recommendations to address issues surrounding medical errors. Some of the recommendations involve roles and functions typically performed by states. The IOM recommendations included: (1) reporting of information concerning serious adverse events to states; (2) implementation of meaningful patient safety programs with defined executive responsibility; (3) purchaser-developed incentives for health care organizations to demonstrate continuous improvement to patient safety; and (4) periodic re-examination and re-licensing of health care professionals.

• In response to the IOM report, health care organizations in Virginia have formed a coalition called Virginians Improving Patient Care and Safety (VIPCS). One of the goals of VIPCS is the development of better systems to support health professionals and to ensure safe practices.

• Several national organizations, including the National Patient Safety Foundation established by the American Medical Association, are also seeking to promote patient safety and advocate best practices.

• The Joint Commission on Accreditation of Health Care Organizations (JCAHO) monitors "sentinel events," which are unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. Health care organizations are encouraged, but not required, to voluntarily report sentinel events to JCAHO. Since 1995, JCAHO has received approximately 800 reports of sentinel events for the entire United States. The number of these that have been voluntarily reported has been rather low, due to liability concerns on the part of health care providers.

• Purchasers of health care services, particularly large purchasers, are a potential source of significant influence to promote patient safety throughout the health care delivery system. However, only 34 percent of respondents to a JCHC staff survey of hospitals agree that health plans have established expectations for patient safety improvements on the part of providers.

• Patient safety issues are addressed, at least indirectly, through various state and federal regulatory activities, including Medicare requirements and investigation of sentinel events by the Virginia Department of Health.

• The Department of Health Professions (DHP) is now using medical malpractice payment information as a basis for commencing standard of care investigations. DHP is also making progress towards implementing an Internet-based physician profiling system which will contain a variety of information including final disciplinary actions and medical malpractice awards and settlements.

• Hospital incident reporting systems are intended to identify events that represent a variance from established policies and procedures (e.g., a patient fall, medication error, etc.). Virtually all hospitals that responded to a JCHC survey report that their systems are administered in a non-punitive manner in support of quality assurance efforts. However, many survey respondents also cited factors believed to serve as barriers to the internal reporting of incidents, such as an institutional "culture of blame" and concerns about malpractice litigation.

• Hospital risk management and quality assurance information is generally protected from discovery in litigation. However, some health care providers cite the need for statutory protections from legal discovery to be specifically extended to any type of external reporting system for adverse events.

• Virginia's patient level database, maintained by Virginia Health Information (VHI), contains certain data that are related to patient safety. These data (known as "e-codes") pertain to surgical and medical "misadventures," adverse drug effects, and surgical and medical procedures that are the cause of an abnormal reaction. These data indicate a very small, but increasing, percentage of inpatient hospital discharges for which such events were reported. Forty-six percent of the JCHC survey respondents agreed that such data have potential value for evaluating adverse medical events in Virginia.

• The federal and state governments are continuing to search for ways to effectively and responsibly address the broad range of issues identified in the IOM report. At the federal level, a national agenda for patient safety research is being developed. At the state level, efforts are continuing to evaluate the various types of adverse event reporting systems that are in operation. In Virginia, VIPCS is continuing to work on patient safety issues, and is developing a patient safety brochure for distribution to consumers.

A number of policy options were offered for consideration by the Joint Commission on Health Care regarding the issues discussed in this report. These policy options are listed on pages 55-57.

Public comments were solicited on the draft report. A summary of the public comments is attached as Appendix B.