The Association of State and Territorial Health Health Officials (ASTHO)

The Association of State and Territorial Health Officials (ASTHO) commends the Agency for Healthcare Research and Quality (AHRQ) and the Quality Interagency Coordination Task Force (QuIC) for convening this first National Summit on Medical Errors and Patient Safety Research. Your consistent leadership to develop the information needed by policymakers is greatly appreciated.

ASTHO also commends the Institute of Medicine (IOM) for publishing its report, "To Err is Human: Building a Safer Health Care System." This report served a valuable function in raising national awareness of medical errors as a possible leading cause of death in the United States. The IOM Report, along with the Report of the Quality Interagency Coordination Task Force (QuIC), provides a useful framework of recommendations to begin discussions and take actions to make our health care system safer.

ASTHO believes that the proposals for mandatory state-based national reporting raise important policy and data collection capacity questions that should be prioritized in any proposed research agenda. We further recognize that without such research, there may not yet be sufficient consensus among stakeholders to support successful implementation of mandatory state reporting systems. To address this situation, ASTHO recommends and supports efforts to identify, collect, and disseminate more information on existing state reporting systems, and encourages AHRQ and others to continue to develop and foster forums like this one in which these issues can be discussed and resolved.

ASTHO specifically recommends further research on what state-based systems will best support and enhance patient safety, focusing on the following questions:

• How have states been able to demonstrate improvements in patient safety and declines in medical errors linked to the institution of a reporting system?
• What are the start-up and ongoing costs associated with operating a reporting system?
• Are there observed differences between states with mandatory adverse event reporting and states with voluntary reporting, particularly in the areas of start-up and operating costs; factors contributing to the decision about being mandatory or not; outcomes; and feasibility to conduct follow-up activities?
• What types of patient safety improvement efforts have been generated based on collected data? Have some been more successful than others (i.e., has anything been tried that did not work and why?)
• How were partnerships created, particularly with state medical societies and hospital associations, to create support and compliance with existing reporting systems?
• What are the funding sources of existing reporting systems and patient safety improvement efforts?
• Has any state seen either an increase or decrease in malpractice litigation associated with reporting systems?

ASTHO strongly supports efforts to reduce preventable medical errors and improve systems of care. Preventing disease, injury, and disability is central to the mission of state public health agencies. Furthermore, evaluating quality, assuring safety, and mobilizing partnerships to identify and address health problems are essential public health services. ASTHO believes state health departments can play a critical role in providing leadership and expertise to address medical errors and improve patient safety and health care delivery systems. ASTHO also recognizes the need for shared responsibility and collaboration of all health system stakeholders -- including physicians and allied health care providers, hospitals, consumers, purchasers, accrediting organizations, and others in this effort.

Finally, ASTHO appreciates the ARHQ, QuIC, and IOM’s thoughtful presentation of the infrastructure resources needed by states to more effectively address medical errors. ASTHO concurs that the focus of any research and reporting systems should be on using information to identify and make systems improvements that enhance patient safety, rather than simply on collecting data. This requires sustained investments in the workforce and information systems that are fundamental to a strong public health system. We look forward to working with all health system stakeholders to further the research base and enhance patient safety, with the ultimate goal of improving population health status.

The Association of State and Territorial Health Officials (ASTHO) is the national non-profit organization representing the official state and territorial public health agencies of the United States, the U.S. Territories, and the District of Columbia. ASTHO’s members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound national public health policy, and to helping assure excellence in state-based public health practice.

Current as of September 2000

Internet Citation:

Association of State and Territorial Health Officials (ASTHO). Additional Statement. National Summit on Medical Errors and Patient Safety Research. September 2000. http://www.quic.gov/summit/aastho.htm

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