8:00 p.m. eastern on c-span. >> medical doctors specializing in patient safety called for a patient's bill of rights that recent hearing on medical errors lose the senate subcommittee on health and beijing examined preventable medical errors that could lead to death or serious financial problems to correct medical mistakes. this program is just over 90 minutes. [inaudible conversations] [inaudible cover stationnversat

>> i think in a sense the discussion we are going to have today, people all over this country. in a sense that many of us included myself, have seen folks go into a hospital for one problem or another and end coming out different than it went in and sometimes dying as a result. what is widely known is the major cause of death in the united states today is the heart disease, a serious problem. the second leading cause of death is cancer.

according to the 2010 cdc report, 597,000 people died of heart disease, 574,000 died of cancer. what is not widely known and in fact what the function of this hearing is about and i hope to do my best with the help of my fellow senators and members of the panel is to start focusing attention on the third leading cause of death in the united states of america and that will come as the great surprise and the third leading cause of death in this country has to do with preventable medical errors in hospitals. recent article published in the journal of patient safety estimates that as many as 440,000 people year may die from preventable medical errors in hospitals. 440,000 year.

that could be more than a thousand day. tens of thousands also died from preventable mistakes outside the hospital such as that from this diagnoses or injuries with medications. new >> caller: years ago the institute of medicine published a report that is a well-publicized report entitled to error is human which found as many as 98,000 people die in hospitals each year due to preventable medical errors. according to a 2010 report, in more recent report from the department of health and human services -- many die from preventable adverse effect in hospitals. according to the cdc one in 25 hospital patients gets an infection from being in the hospital. in 2011 these hospitals required infections cost 700,000 people to get sick and 70,000 people to

die. clearly those errors cause an immense amount of human suffering but they are also from a financial point of view very expensive to the government and for individual families. medical errors cost the u.s. health care system $17 billion in 2008 comment and when indirect costs a taken into account like lost productivity due to missed workdays, medical errors may cause nearly $1 trillion each year. in the midst of this situation, which we will be discussing today and i think we agree is not just an american issue, this is an issue taking place all over the world. countries all of the world are trying to combat it. the good news is there has been progress made in recent years and we will hear from our

panelists about the progress that has been made and more importantly where we have to go. but power is we understand that tragedy occurs, people die for all kinds of reasons that the tragedy we are talking about here are deaths taking place is that should not be taking place and that is what we are going to be focusing on. some of the advances we have seen, we are discussing these this morning come from following practices interestingly enough that have been established in high stakes field like aviation and nuclear safety, obviously people ideal with very dangerous situations. for example for the implementation of checklists, infection rates in our country have dropped dramatically, advances in technology like electronic prescribing can catch medication errors and robotic tools which creates smaller incisions during surgery can reduce the risk of infection.

there has been increased attention to something that seems pretty obvious, the need to watch and on a regular basis in hospitals. i would assume that would be pretty obvious. medical care in the country is the cause of disability and death as well as huge financial cost to our nation. this is a problem that has not received anywhere near the attention it deserves and i hope we can begin the process by focusing a spotlight on this matter of such grave consequence. senator warren. >> i don't have an opening statement. i am eager to get to the testimony and to the questions. >> senator whitehouse. >> thank you for holding this hearing. i thank the chairman for allowing this to go forward because this is an extraordinarily important issue for all the work and fighting that has surrounded the affordable care act, there remains in large fundamental

problem in the american health care system which is that it costs 50% more than the most inefficient other industrialized country's health care system in the world. we have an inefficiently premium of 50% over the major economies that we compete with and the price of that inefficiency is paid also in hundreds of thousands of american lives. for all the good that the affordable care act did those problems remain before us and i am delighted to be here. i in particular want to welcome dr. peter pronovost who we have never met before but he is the architect of what was called the keystone project in michigan and -- >> it different keystone project, i want to make it clear. >> i established something called the road island quality institute which took the keystone principles and applied

it in our intensive care units and dramatically reduced the infections in our intensive care unit, pretty much statistically zero. interestingly also had the side effect of making the nursing staff in the intensive care units empowered enough the nursing turnover experienced considerable drop-off that they were so excited about what they would doing. there are ways to do this, when talking about saving people's live, saving money is a secondary concern but here we have a very fortuitous alignment between saving lives and saving money. this is a very important topic and i applaud you for having brought this wonderful group of witnesses together and holding this hearing, thank you. >> let's get to work. dr. john james is the founder. i am going to introduce you and we will go down the line.

dr. john james is founder of patient safety america. in september of 2013 dr. james published an article published in the journal of patient safety which found somewhere between 210 and 440,000 americans die each year from preventable medical harm in the hospital. dr. james retired in early 2014 s nasa's chief toxicologist, received his ph.d. in that policy from the university of maryland, thanks for being with us. bring the mike up to you, make sure it is on. >> the counter didn't start. is that the counter? >> this is not nasa. we will start with the nasa guy. >> thank the german sanders for inviting me

patient safety. cheese seminal event that turned into an activist in trading late summer of 2002. alex was 19 years old and had returned to his junior year at baylor university. when running in the evening of august 2015 collapse on the university campus, self recovered but was taken to a local hospital. he was evaluated for four days by cardiologists and underwent elective physiology tests in another hospital. five days after he was discharged he had a follow-up with the physician in training who gave him a clean bill of health and in a week he returned to running list of timber 15 for approximately two weeks after he resumed running i received a call late in the evening that he had collapsed again while running but this time his heart had stopped and was in a deep unresponsive coma. he died three days later in the hospital where he was first taken for evaluation. once he got his medical records that discovered my suspicions about his cause of death were born out. during his first hospitalization

i had noted his lead cardiologists that is potassium was low and this might have been the cause of his initial collapse. discounted the possibility and replacement was never administered. as i deduced much later at least three catastrophic errors were made by his doctors, when they failed to apply guideline for the national council on potassium and clinical practice, failed to diagnose cutie syndrome and they knew he should not return to running, wrote this in his medical records but never warned him not to run. alex was discharged instructions in writing were to drive--not to drive for 24 hours. i have written about the details of this poor quality care in a book published in 2007. many physicians read that book and none disputed my analysis. an elective physiologist after reading my book of terms to me in an e-mail that she too had been frustrated in attempts to better audiologist's colleagues to pay more attention to potassium but apparently i gained a measure of credibility in the cardiology community because of the past few years i

completed 25 reviews of cardiology manuscripts for cardiology journal. as i unravel the errors in my son's care and discovered his cardiac mri was never done properly at began to realize medical errors like those that ended his life were not uncommon. i saw the institute of medicine estimated 98,000 americans die each year from medical errors in hospitals. other reputable estimates at the time were 284,000 deaths, remarkably if the heart patient does survive then with few exceptions hospital will be paid to fix the harm. how much harm is there? by 2009 nestle for studies that use the global trigger to identify adverse incidents of medical records. two were peer reviewed studies and two were from the office of inspector general. this tool was more efficient at identifying adverse events than an guided physician reviews the individual studies gave a

remarkably consistent picture of the prevalence of lethal adverse events. in addition of this study's showed medical records often do not contain evidence that is discoverable of harm when patients know they were seriously harmed. in 2013 not published a study in the journal of patient safety. the math behind my calculation is simple. there is no voodoo statistics here. there were 34 million hospitalizations in 2007 of approximately nine% involved lethal adverse events and of those approximately 69% on average were judged to be preventable. this is an estimate of 210,000. however, the global trigger was the detecting errors that mr. many errors of omission, communication, context and diagnosis. it would not have detected any of the catastrophic errors made by my son's doctors. events which no evidence appears

in the medical record correcting for these limitations yields an estimate of 400,000 lives that are shortened by preventable landers events each year. what are the solutions? the senate should establish a stand-alone committee on improving patient safety. it should establish a national patient safety board. should pass the national patients' bill of rights to include legally binding and forced rights to give jimmy informed consent to know the safety record of their physician outpatient clinic nursing home and hospital, no cause for tests and elected procedures before hand, transport accountability for evidence based care, to know when drugs are prescribed, to be warned about that livestock polices, to have care by teams of professionals that build individual and team excellence to 36 degree performance reviews, these are anonymous reviews by patients,

subordinates, colleagues and leaders anonymously. in my opinion save the patient is not going to improve substantially until the playing field between the ill patients and the health care industry is levels by an in forced bill of rights. despite our higher per-capita expenditures on health care our industry ranks last overall compared to systems in other developed countries. that needs to change. i thank you for your attention. >> thank you. senator warren, you were going to introduce the next panelist lou >> i have the honor of introducing dr. -- wrong one -- introducing dr. ashish jha. ashish jha is a professor of health policy and management at the harvard school of public health. he is also a practicing physician of internal medicine at the boston the a. ashish jha received an

undergraduate degree from columbia college and his medical degree and his master's degree in the masters of public health from harvard university. ashish jha founded the initiative on global health quality at the harvard school of public health and his research focuses on improving the quality and reducing the cost of health care in the united states and around the world. in 2013 ashish jha was elected to the institute of medicine. his work has been groundbreaking and it is a great honor to have him here today. >> thank you for being with us. >> my pleasure. thank you for that very warm introduction. it has been 15 years since the iom estimated 100,000 americans die each year from preventable medical errors. when they first came out with that number it was so staggeringly large most people wondered could it possibly be

right? the evidence 15 years later in hindsight, the evidence is in and the evidence is clear that the i o m probably got it wrong. it was clearly an underestimates of the toll of human suffering that goes on from presentable medical errors. beyond the problem with the estimate and exactly how many people are suffering from these injuries there is a second pressing question, it has been 15 years and a reasonable person might ask how much progress we made in the last 15 years, what have we done? you will hear from peter pronovost and others about areas where i think we have had progress but the fundamental question is if i walk into an american hospital today, am i demonstrably clearly savored that i would have been 15 years ago? the unfortunate answer is no. we have not moved the needle in

any meaningful demonstrable way overall in certain areas things are better in certain areas things are probably worse but we are not substantially better off compared to where we were. the last piece of distressing news in my mind is as senator sanders alluded to, is this a uniquely american problem? is this something other countries struggle with? when we have looked across the globe what we find is no matter where you look, the size, the scope, the complexity of the problems are remarkably similar. and when we compare ourselves to other high-income countries the u.s. is in the middle of the pack. we are better in some areas, worse in others but there is no country i can point to that i can say they really get it right consistently. i think there's a tremendous opportunity for leadership he. beyond that distressing stuff let's talk about the progress that has been made. i want to begin by talking about

preventable infections because that is the place we have made the greatest progress and when i talk about that topic i usually point to two agents that had a central role in reducing infections. one of them is the speaker two down from me, peter pronovost. peter pronovost's work has probably saved tens of thousands of lives if not more. i won't talk about it because he will do a better job explaining it. the other agents were talking about is the cdc through its surveillance programs. surveillance programs around health care associated infections have been i think fundamental to the improvement we have seen. if you take a step back and ask how is it we improve? how do we get better at anything in our lives? the key element is day and metrics that are valid and credible. if you don't have data and metrics you don't know how you are doing, you don't know how you compare to anyone else and have no way to judge whether

your efforts are making a difference or not and the cdc has been a leader in this area in helping develop validated metrics of infections and feeding that information back to hospitals and i think that has been fundamentally important in the kinds of improvements we have seen. here we are 15 years later and the question we should ask is how do we avoid another hearing five or ten years down the road, we're 25 years after the report we still have not made much progress. none of us wants to be there. how do we avoid that? how do we begin to make real progress? i have three suggestions that are doable. first, we need to expand the efforts of the cdc. there is no reason to think what they have done around health care associated infections they can't do in other areas like embolism or medication errors that can partner with the fda. the cdc has a phenomenal care record, this is a public health problem, the cdc is our public

health agency. they have a central role to play. the country is in the midst of digitizing our records system, we have seen phenomenal progress in adopting any use of electronic health records. that has a lot of potential but the potential won't be realized unless those tools are focused on improving patient safety. the tools themselves won't automatically do it and we need to make that a priority and there are specific things the administration and congress can do in that ariane the third is incentives. we can't continue to have unsafe medical care be a regular part of the way we do business in health care and care is an important role to play. medicare has an important role to play. the aca takes important steps but we can do more. we have a cadre of physicians and nurses in this country who are incredibly well trained,

dedicated, caring individuals who go to work every day trying to do the best for their patients. we have a system that fails them and a system that fails the patients who expect and really deserve health care that is not formally effective but safe and improves their health, not arms it. thank you very much. >> thank you very much. senator warren, you were going to introduce tejal gandhi. >> dr. tejal gandhi is an associate professor of medicine at harvard medical school and the president of the national patient safety foundation. she received her undergraduate degree from cornell university and her medical degree and a master's in public health degrees from harvard university. before serving and the national patient safety foundation, dr. tejal gandhi was chief quality and safety officer at partner's

health care and served as executive director of quality and safety at brigham women's hospital. tejal gandhi's research has focused on patient safety and on how using information technology can help reduce errors in health care. in 2009 she received the eisenberg patient safety award in recognition of her research on the epidemiology and prevention of medical errors so again we have someone who has done extraordinary research and put it into practice. thank you for being here. >> not only is at. >> tejal gandhi. >> thank you, senator warren and chairman sanders for the invitation to speak on a critical topic, the topic of patient safety. i would like to talk about ambulatory patients safety and the priorities and challenges we currently face. the focus of patient safety efforts over the past 15 years as you heard about has been on

improving patients' safety in the hospital setting. it is important to remember most health care is given outside hospitals in diapers ambulatory settings such as primary care and specialist practices, nursing homes, rehabilitation centers, dialysis centers, ambulatory surgical centers and that just means a few. the safety issues in each of these settings differ and little is known about what those distinct safety issues are. we need better data in all of these settings to understand the risks and opportunities for improvement. the ambulatory settings we know about in terms of safety shoes is primary care. i will touch on three areas in particular. medication safety, missed delayed diagnosis and transitions of care. studies to show medication errors are common in primary care and adverse drug events or injuries due to drugs occur in up to 25% of patients within 30 days of being described the drug. in addition at the medication safety issue in ambulatory that is not an issue in hospitals is

the issue of non adherence. one of four prescriptions never get filled by patients and these are prescriptions for important conditions like hypertension or diabetes. better strategies are needed for medication errors but also to improve adherence. delayed diagnosis is a key issue. in the malpractice world this is the most common type of outpatient malpractice claims, usually missed and delayed diagnosis of cancer in primary care. mist and delayed diagnosis is complex. the most common breakdowns that occur include failing to order an appropriate test as well as failure to follow up on test results. we cannot just say try harder rand think better. we need better systems to minimize cognitive errors and minimize failing to think to water tests such as computerized algorithms known as decision support. better systems are needed to manage test results to insure every test that gets ordered is completed, the provider receives

the results and notifies the patient. leslie transitions of care. transitions occur all the time in health care. patients move from hospitals to homes, from nursing homes to emergency departments, from rehabilitation centers to home ward visiting nursing. we know transitions are high risk times when key pieces of information can be lost. for example one study found after hospital discharge, which in three to five days 1-third of patients taking medications differently than had been prescribed in the hospital. another study showed 40% of patients are discharged with test results that are pending, that have not come back yet and these results are often not seen by their subsequent primary care provider. efforts have been under way across the country to improve transitions such as having postage charge, what phone calls to patients and better electronic systems to ensure complete information transfer but there is much work and still needs to be done for all these

transitions. a major theme throughout ambulatory safety is patient engage in. park during with patients to achieve savor care. clinicians need to be better engage with patients to ensure patients understand and agree with their care plan. for example i'm sure patients understand why the medication or test is ordered and why is important to understand what the plan is after leaving the hospital. this needs to be a true partnership in order to ensure the goals of the patient ibm at. to summarize there are numerous ambulatory settings, all with unique safety issues that need more focused attention. we need to first develop a more robust ambulatory infrastructure with mechanisms for error reporting, culture change and process redesign across all the settings i mentioned of the second we need to identify better measures, metrics of ambulatory safety and conduct more research to understand what the safety risks are in these settings and how they can be improved. you heard about metrics and the

metrics that do exist. there are few if any that exist for the ambulatory settings and lastly we need to continue to redesign care from a system that human factors approach and ensure we are engaging patients in this process so we can deliver the safest care. >> thank you very much. our next panelist is dr. peter pronovost, a practicing anesthesiologists and critical care physician, director of the armstrong institute for patient safety and quality at johns hopkins. he serves as john hopkins senior vice president for patient safety and quality. peter pronovost developed assigned to the clipper and checklists method for reducing infections associated with catheters and serves in an advisory capacity for the who's world alliance for patient safety. in 2008 he won a fellowship

genius grant. you make us all very nervous here. >> tell my daughter that. >> award for his work and patience safety received his m.d. and ph.d. from john tompkins university. thanks for being with us. >> thank you, you should take comfort to know that your states are actively using the checklist that have dramatically reduced their infections. thank you for hosting this important hearings and for inviting me to testify. importantly, thank you for the great work you do to keep this country strong. ..

because outside of health care infections we cannot have an accurate monitoring system to retain a look at, or the public look at how often harm happens and we should. also asked you why is it that when a death happens one at a time silently it warrants less attention when death happens in groups of five or tens or thousands. what these numbers say is that every day at 747, two of them are crushing. every two months, 9/11 is occurring. we would not tolerate that degree of preventable harm with any other form because the

something of people who lose death one at a time is just as real as those who lose it in groups of tens or thousands. our collective action in patient safety pales in comparison to the magnitude of the problem today. medicine today invest heavily in information technology, yet the promised improvements in patient safety and productivity have frankly not been realized. productivity and health care has been negative since 1990. but we have a success story to guide us. luckily i have been blessed to be part of that. these central line infections used to kill as many people as breast or prostate cancer each year. that's the scope of the, 30,000. and now with collective efforts from the cdc on how to measure with work from nih to understand science of how to improve it with funding from -- tuple groups together and work to reduce it, these infections are down 70% since reported.

agencies have produced the infection rate from six, the 1.3, nonteaching hospitals from 4.1 to 1.1. saving lives, saving money, producing more productive americans. so why did it work? what do we learn and what policies should we implement? it worked i think because we had clear goals and ballot measures. it worked because we have good science to guide us about what to do. worked because we engaged clinicians to professionalism and to work because we transfer of reported infections and had accountability. yet on a deeper level when theye partner with our anthropologists and sociologists find out why, what we found was that it worked because clinicians told a different story. prior to this we all said, myself included, these infections are inevitable. but with this work we said they

are preventable, and i could do something about it. stories are powerful forces for change, whether it's jfk, i want to put a man on the moon, martin luther king i have a dream, ronald reagan saying tear down this wall. change the story it would change everything. what other stories holding us back or where do we need for stores? i think we need to first, harm is preventable and not tolerable. that patients safety is a science and science must guided. said systems must be designed to deliver safety are not based on the heroism of our clinicians. so what might we do for policy thinks? first as a she said charge the cdc with developing monitoring and transparency reporting the incident rates of the top causes of hard. they do for a hiv canno can i dr others. create standards for the porting of health care quality and cost measures and to what you did in

1934 when you created the security and exchange act so that we now know we can look at financial statements and make sure they're accurate. right now we have no guarantee that the measures we are reporting or acted. johns hopkins hospital was both congratulate and criticized on the exact same measure for the exact same time period for blister infection. when we looked, the one where paid on using administrative data got it right there being -- 13% of the time. we'll hire nurses to code better, not to improve care and, frankly, that's not what these instead should be driving our hospitals to do. it is disrespectful of our loved ones do not have accurate data. data just isn't up to the task or least not to be transparent about how accurate it is not saying it is good enough or it is not good enough. third, we need to support our to advance the science of patient safety to make sure every workforce to detain like -- have

the skills to do this and to make sure we and promote programs. finally, we need to invest in systems engineering and learning labs to improve productivity and safety. we rely too much on heroism. our nurses answer a false alarm every 90 seconds. we spent two ftes are nursing a 30 of them hospital, $8 billion manual doublechecking pain medicine because the devices don't talk to each other and it's completely inaccurate. we had success with the checklist but blister infections are one or. patients with chronic disease, patient and hospitals are risk for a dozen arms. every harm has a checklist. every checklist might have five or 10 items. every item they need to happen three or four times a day. you add it up and you have clinicians expected to do 100-200 things every day and no

information system less than. what we have now, senators, would be the equivalent of if boeing is building a plane with many subcontractors as they do in the maker of the landing gear said i don't want to send a signal to the cockpit to tell you the landing gear is up or down. you will have to guess. and boeing says no problem. we will still buy it, even though it will cause of deaths. we need to start doing another good great thing because the rails is 25 patients died during this hearing. >> dr. pronovost, thank very much. dr. joye dish is a professor at the university of minnesota school of nursing. she is provide leadership to several national organizations working to improve patient safety. this included pastor of the present of both the american association of clinical care nurses, the american academy of nursing as well as board share for aarp.

the past 12 you should been a faculty leader of the quality of safety education for nurses and initiative which has educated more than 1500 nursing faculty and safety scientists. dr. disch received her degree in nursing from university of wisconsin-madison, and her ph.d from university of michigan. dr. disch, thanks for being with us. >> good morning, thank you -- [inaudible] >> and again good morning. thank you, chairman sanders and others of the subcommittee. for hosting is very important hearing. i'd like to begin my comments by providing some context. first while the subcommittee is to be commended for tackling this challenging issue, i believe the title understates the problem. were not only dealing with 1000 preventable deaths a day but 1000 preventable deaths and 10,000 preventable serious complications a day. which can result in a quality of life it might be comparable to death for some such as the woman

from minnesota who underwent a bilateral mastectomy for cancer only to find out shortly after surgery that had been a mixup in the biopsy report and she had not had cancer. second, this is possibly the most bipartisan issue that exists today. since most of us have either been patients or family members or will be in the future. it affects all of us. and third, this is one of the deep issues that money a loan cannot solve as often say when lecture to nursing students, even bill gates cannot guarantee safe care for himself or his family. this morning i will highlight some of the factors, key factors influencing patient safety america three recommendations. first, we know the factors that compromise safety that many have been mentioned. the complexity of health care, the patchwork nature of our health care system, the perverse financial incentives and the growth of technology which can be a blessing and a curse.

in addition system barriers make doing the right thing hard and time pressures reinforce doing things quickly without fixing the underlying problems. we have strong traditions in health care that discourage people from speaking up or examining problems from a system viewpoint. interestingly the joint commission has found three factors to be most commonly involved in serious preventable events. one, human factors which include things like staffing mix, levels, inadequate orientation, fatigue, destruction, complacency, bias. two, communication others whether they be oral, written, electronic. again technology can help but it does at burton. and then third, leadership. this suggest rather than fixing individual problems we must take a systems approach and it up fundamental changes in our health care organization. i propose three strategies that

when taken together with those of my colleagues will make a difference. first, we must ensure we have an adequate number of registered nurses, properly educated with a voice for decision-making about staffing and patient care at the bedside. this may seem obvious. registered nurses are the cornerstone of the american health care system. they form the largest element with 2.7 million. they are there 24/7, and are on the ground floor at care delivered to get the nurses these the skin breakdown that lead to a bedsore. it is the nursing is the older woman's unsteady gait and put in place strategies to prevent a fall. the nurse is often the last line of defense. unfortunately, the bureau of labor statistics anticipate a shortage of 1 million nurses by 2022 due to the growing demand and the need to replace those retiring. the good news is a more people are entering nursing and older

nurses are working longer. but these increases are insufficient to meet projected demand. of great concern is the u.s. nurses school turned away at least 80,000 qualified applicants in 2012 due to inadequate resources. more than just preparing more nurses come research shows when it registered nurses with a minimum of a baccalaureate degree and an adequate staffing levels and hospitals which has been shown to decrease patient martelly. however, only 50% of nurses have a baccalaureate or higher degree in this country. so we need an adequate number of nurses with a minimum of a baccalaureate degree and/or actively involved as dr. pronovost mentioned at johns hopkins in making decisions and interpreting safe levels of staffing. the second recommendation is we must engage the patient and family as full partners in care. some would say control and full

partner. practice is organized around what is most convenient for the provided, that there are the health care organization and not the patient. yet we know that the outcomes can be achieved at lower costs when patients partner with their care providers and assume responsibility for helping manage on health care. and we know that while clinicians at the medical expertise and know the site, the patient and their family knows the individual best and what works for him/her. third, we must change the culture of health care and one committed to safety. and again this might be obvious. aren't all hospitals concerned about safety? of course they are. at the extent to which this becomes a priority and adequate resources are allocated very sector minister. we must shift from a bureaucratic patriarchal model by some professional economy and wanted interdependence and relentless focus on safety. we need leaders are passionate

advocates for preventing harm, who commit resources for process improvement and actual leaders who know what they don't know and invite others to help solve problems. in conclusion this is enormous change. it would be easier if we could just throw money at it. to start, we can use the principles and encourage organizations to adopt the principles of high reliability organizations where everyone has a laser focus on safety, with our systems in place to improve processes and where everyone including patients and families is encouraged to speak up and report errors and unsafe conditions. there are those organizations. we should make sure they get visibility and are immolated. thank you. >> dr. disch, thank you very much. next panelist is lisa mcgiffert with the director of the safe patient project of consumers union, the policy inaction division of consumer reports.

ms. mcgiffert tricks the multistate campaign to initiate infection reporting legislation which was passed in four southern states and d.c. and raise public awareness for the prevention of medical ms. mcgiffert serves at the consumer liaison to the cdc health care infection control practices advisory committee and is a consumer representative on the national quality forum health care associated infections the steering committee. prior to joining consumers union she worked for the texas senate committee on health and human services. ms. mcgiffert, thanks very much for being with us. >> thank you, senator sanders, for holding this hearing, and to senators white house, murphy and warren for being here. i'm not going to go over this statistic because they been covered but i think i do want to make a statement that the response from policymakers, health care leaders and regulators does not come close to matc matching the scope of ts problem. and that is exactly the focus of this hearing as i understand it. i want to talk about the

patients because the impact on patients very and community where from minor harm to death, regardless of the scope of the impact of a medical error. most people's lives are affected and they are affected beyond the health care that they need or the physical response. people who were harmed lose their jobs. they lose their homes. they lose their health insurance. many go bankrupt trying to pay the medical bills that they would not have had had they not been harmed on health care provider a sought help from. these are very real consequences of a failure to take action to eliminate medical errors. they are our assisters and brothers, parents and children, and their disabled come and many of them are dead because of these events. patients have been betrayed by the system in which they place their trust, not because we expect perfection but because we

trust they will use the best knowledge, adheres to best practices, painting to do what we tell them and ask of them, understand that when we pay for their services, we expect it will include doing all they can to keep us safe from harm. and when they make a mistake, they will realize it, admit it and correct it. 14 years my project i consumers union has conducted a national campaign to eliminate hospital infections and medical errors to a major strategy has been reaching the goal, reaching this goal is to improve public transparency. in 2003 we develop model legislation to create hospital acquired infection reporting, took it across the country recruited people who have been harmed to help us pass these bills, and now 31 states and d.c. have these laws. as most of you know, a federal program requires reporting of

infections. the creation of the cdc national healthcare safety network was essential to making this happen. that was greater right around the time when we're going across the country in many of the states adopted that as a way it would report infactions. so it is true we have this system in place that is a standardized system we could use to collect information about more infections as well as medical errors. and that is really essential in moving us forward. public disclosure is a critical element in preventing these events from happening because it informs people about health care outcomes and motivates providers to do more to prevent errors. work also includes working with people have been harmed and i'm very grateful for all that they have taught me. i wish that all could be with me today. i know many of them are watching, many of them sent letters to congress last week

urging them straight a national patient safety board and to step up their efforts to address this national crisis. i'd like to touch quickly on three things, transparency, oversight, and accountability. we have an infrastructure for oversight of health care provided by hospitals and physicians and others but it doesn't work very well for consumers. seeking reliable information over patients trusting that oversight agencies will respond promptly when standards of care are not followed. public transparency to address some of these issues. i want to be clear we are talking about transparency of the events, not patient related information. our system is through secretive and it needs to change. the other thing, the government holds lots of information about harm that is being done that is not readily available to the public and they could make it more easily available. the oversight system does not work for patients. we have a network of oversight at the state level and at the federal level, and it is not

responsive. our health care system that does save lives everyday, we all know that that happens, but it's also rife with the dishonesty and stonewalling when patients are harmed. linda carswell whose husband died suddenly in a texas hospital had to fight in court for years to get his heart back, noted early on could have revealed that he died due communications given in the hospital. lisa cold who barely survived discovered photo summer hospital records were not submitted to the medical board when asked for information. and hospital boards and leadership's come and leaders in hospitals choose to spend their money on things that will bring in profits rather than activities that will improve the safety of patients. we need someone on our side to look over this system. that is why we're asking for an independent national patient safety board. we need someone to listen to patients because they offer real

insights into what needs to be done. we need someone to make this network of systems work for us. i'd be happy to talk to you more about this is the question and answer. >> thank you very much, ms. mcgiffert, for your testimony. and thank you all. i think it's an excellent testimony. let me begin the questioning. dr. jha, you work for the g8 occasion, right? and chairman of the pressure i'm chairman of the senate committee of veterans affairs and we been hearing a lot of front pages about problems with the va. we have to do with those problems. but i think as many of the panels have indicated we haven't heard a whole lot about -- i think dr. pronovost, you indicate would evoke secondly people died from errors, but used the analogy of two large airplanes a day going to is at 500 day, 1000, we don't know. so my first question is, how

come this story is not on the front pages every single day? 500 people every single day by combat also is a big story. that's one question. why is this issue not getting the kind of attention that it deserves? who wants to start? okay, dr. jha. >> two quick points. one, to that question, senator, when people go to the hospital they are sick. and it is very easy to confuse the fact that somebody might have died because of a natural consequence of the disease versus they died because of the complications from a medical error. and the bottom line is that it is taken work like to work like dr. pronovost is done to prove to all of us that many of these deaths are not a natural consequence of the underlying disease.

they are purely failures of the system to address the problem. and has been a wakeup call for clinicians, physicians, nurses and other we can do so much better. >> good, let me just -- dr. pronovost? >> i think there are three reasons that it hasn't get in -- the first is that we've labeled so much harm as inevitable, the result of being sick that we now have is preventable. the difference in harm estimates between the iom report of 1999 and today isn't that kerry got worse. it's just that all these other deaths that we put in the inevitable bucket cannot be moved into the preventable bucket and there's frankly more than we probably should move. second is that deaths occur alone one at a time and silently, it doesn't get the media attention. if you look at compared to the mining in west virginia or the automobile, the number of deaths

pale come into tents, not in the hundreds a day but look at the media because one debt at a time doesn't garner it. third, if you look at what drives research agenda, or your work, it is disease advocacy groups. so the alzheimer's groups, breast cancer, and there is no advocacy group with our for patient safety because there are many different diseases and it their needs to be. nih funding or your work is you have to answer to this constituents. they are powerful and we lack that. >> i apologize for cutting people off but we only have five minutes to ask questions. let me pick up on a point that ms. mcgiffert raised and that is the issue of transparency. if i go into the hospital, is there public information about the level of infection at the hospital or other preventable deaths? i mean, do we have the

information that would make the consumer, allowed consumer to make a good choice, to me people have died or gotten sick in the hospital? >> we are beginning to have information. we don't know if the whole hospital is safe, and we do know that people often are treated in different parts of the hospital. when it comes to surgery it probably depends on what state you're in whether the sugar you're getting is going to be published. in washington state they published it in the implant surgery. so you're in luck there but they're not in luck in texas and the federal government doesn't require that yet. so we're getting there but it's been very slow over the last 10 years and we really are just getting a small piece of the problem. >> let me just jump in and out of the dr. gandhi next. a wife has an operation, there's

a problem, husband in this case says you did something terrible. maybe there's a threat of a lawsuit. is it not true that many of these settlements will not be made public? that we don't know how many settlements have been made because of poor practice. dr. gandhi, is that an accurate statement? >> that's an accurate statement. so i want to talk about transparency, and you mentioned other infection rates available for someone going into surgery and i think that's getting more available to there are so many other pieces of information that someone needs to know before they go into maybe not going for surgery but maybe they're going to go see a primary care doctor, what do they need to know? the amount of good information available to patients is minimal. i think it's important to give transparency in a couple of different levels. first when he transparency of patients.

with the data, transparency about ayers, transparency about why we're doing the care we are doing. but then there's other levels of transparency we really need to think about. one of the things is a huge lost opportunity is transparency across organizations. so if to point about a malpractice case or even an airtight to delete a malpractice and my hospital fixes it, figures out how to solve it, that does not naturally leave the four walls of the hospital. so things are getting reinvented and things are happening constantly around the country. so i think we need better mechanisms to ensure that sharing across organizations or when these events do occur. >> senator warren. >> thank you, mr. chairman. according to the cdc, about 75,000 people die annually from infactions they get while they're in the hospital. it is a shocking number. we should be doing everything we can to get the 20. we already know about about how

to reduce these deaths. some of the simplest things like better handwashing, more thorough room cleaning, establishing protocols for catheters and ventilator tubes. have shown to reduce these infections. i want to brag a little bit. boston children's hospital, which treats some of the six children in the world, has had terrific success at implementing steps like these. austin children's has not had a single case of ventilator associated pneumonia in the cardiac icu in nearly two years. and not a single catheter associated urinary tract infection in the medical icu for over two years. in other words, i just want to start with what we already know. we know how to make patients safer. unfortunately, it's not helping everywhere. we need a system in place to help the adoption of these practices. so my question is this.

can you help us understand why certain health care entities have not yet adopted straightforward, proven technics to reduce these infections? dr. jha, would you like to start? >> i would be happy to come and it's a terrific question. fundamentally a question in front of us is how do we have an industry where you have cheap, easy interventions that save lives, save money, and not every single person is using it everyday? like there's a disconnect. something doesn't make sense. and it strikes me that when a look at places a boston children's and a look at hopkins and he's leading organizations, it is what they are doing is driven by passionate leaders who care deeply despite all the incentives in the system that don't give them any reward for doing this kind of stuff. that's the problem. if we have a system that relies on heroes and great leaders and people like dr. pronovost to

solve all of our problems, i'd love to clone this guy. but that is not a policy solution for the problem we have. we've done work that is look at hospital ceos and what determines ceo pay and nonprofit hospital to these are the organizations that have been nonprofit status, quality outcomes, patient safety, none of those things influence the pay of the ceo. and so until we get to a point where the ceo of the hospital is lying awake at night worrying about patient safety, i don't think we're going to really meaningfully move the needle beyond the few leading the organizations that will do it no matter what incentives would put in. >> good. dr. gandhi. >> i want to add it's critical for boards and directors be better educated about this topic are often wards are much refocused on the financial aspect of how hospital is running, especially i stand is a hard financial times for many hospitals but having four directors who understand this

issue and can push it to the organization is also really ke keep. >> good. dr. disch? >> i'd like to add or civil procedures assume that we should be able to say wash your hands. and yet when you get down to even that simple of a basic which we all know is the number one preventive action you can take, it will becomes complex. you need to leaders that will say we are concerned about the finance but you also need the resources in place but even something as simple as washing your hands, the right equipment, new sinks that are accessible, the soap that is there, housekeeping making sure the soap dispensers are filled, that the position comes with a bunch of equipment, where do they put that down? on the floor? i don't think so. it's such a ripple effect that you need equipment, unique people to understand what's going on. i was going to mention about transparency. staff have to understand what's going on with the metrics. so we can do national promoting. we can do information among hospitals but staff need the

feedback that here's our infection rate compares what we're doing but here's what we are improving at all those go do something as simple as handwashing. >> dr. pronovost? >> senator cummings you should bet on a research team with your questions. we rejoice to see what allow the hospital to get to zero, like boston children's verse is not. we part a technique called peer to peer review. they developed it after three mile island. no regulatory roller one nuclear facility visit another. we went into hospitals that were zero and try to understand. what we found is there was no magic bullet but what there was was a clear chain of accountability and practices that led them to get his you. they were zero if the cdc said our goal is or and to look at her rates in the new. they were at zero if they provide immediately support structures. that could infection prevention to educate the. they were zero to the icu director nurse manager owned the problems to we walk in its of what is your right and they knew it, they were zero if they have a culture where nurses could

openly questioned doctors for not using the checklist and that was well received. they were zero if the frontline staff got feedback about their infection rates and the investigated every infection. we know this agenda commend. wages have it implemented but if you did want you may good and a a little bit but you put them all together and just a great program spend i will ask the chair's indulgence if we can follow with this line. what would you change in federal and state requirements, policies, to drive us in that direction? as i say, this is not the part about the cutting edge new magical things would get figure out by things like washing your hands that will drive down the rate of death, the rate of infection. start with you, ms. mcgiffert, and we'll come back. >> a lot of things that can be done to make the payment incentives more meaningful. for example, hospital acquired condition payment program.

but the disincentive is simply cannot pay for the hospitalization during which the event occurred. but that person on medicare has to get wound care, doctor visits back in the hospital, medications, all kinds of expenses that medicare is paying for and that hospitals should be held responsible for the whole, the whole range of things. >> so we have a payment -- >> payment response. >> very powerful. i will ask you duties quickly because i am over. dr. disch? >> the one thing i think about, what minnesota's doing, hospital engagement networks and to bring together the ceos and senior leaders to look at what are we doing and have conversation across institutions which creates the incentive out of your system so much better than ours? they talk among themselves. speaking with some of the official some hospital association, i said, how many of

the ceos in our state do you think are really changing and becoming that only concerned about finance but also the preventable event bottom line? she said, each really changing the dial when i sit down and talk and they shared stories but is not just the ceos but it's the senior team just like was mentioned before, it's got to be medical literature, nursing leadership. that comparison and sharing is happening at the state level. >> dr. pronovost? >> senator warren, right now we have reduced infections dramatically but there are several hundred hospitals who have rates 10 times the national average and there is no accountability outside of leases or the public reporting. they're fully accredited and we know he did these things they can get to sue. i would love to see a start with blood infection because you can't bully him much of a good measure. but we have a good measure for this end we have evidence -- if you're not down low, it's a

leadership failure. no excuses. we could say we need a mechanism to say if your hospital is five, you shouldn't be -- there should be some greater sanction because we know. >> let me pick up on a point. you are saying you know that there's some hospitals that have infection rates 10 times higher than other hospitals. do the american people know who those hospitals are? >> i know about those because of the work of consumers union and several states require public reporting. and there are newspapers, chicago data, baltimore did it, would write newspaper articles listing the hospitals that are high, but outside of that public sanction literally there's no follow-up. you would say okay, you are accredited if you meet the joint commissions, which is great, yet you do the people are dying. who was responsible for making 10 times to light isn't appropriate window you can fix it. what would you do? >> dr. pronovost can will be the

next step? we've got the consumers union of there. what would you do next? >> i think we need either at a federal level over the joint commission but cms should say if you rates, i would start with this one measure because we know the measure is good and the evidence that you can get low is good. >> your right to speak about the national average you could tell jeff a quarter because you have infection rates plummet when you do these things literally immediately, within months, then speed you talk about accreditation. >> correct. >> i apologize. i do want to be sure that dr. jha gets a chance. >> i know. senator whitehouse. >> thank you very much, chairman. the clear accountability that everybody i think it raises a very important signal is hard to develop without clear data. and i'm concerned that there is kind of a power of babel problem

data provider has to report through multiple means of reporting to the federal government. i think in every state multiple means of reporting to the state government, through whatever reporting mechanism the individual insurers that they do business with have built into their systems, through whatever local systems might have been set up if there's a regional or municipal quality initiative, and potentially through their aco process and some of the quality improvement process. by the time you've loaded up all that reporting, two things that happen. reporting begins to eat up the actual repair, and the noise overtakes the signal. so if the hospital gets a bad report, the first thing that i hear them say is oh, that data is not good. if you look at this we're

actually doing better over here. so while we want robust reporting and while some of this is a moving target you need to keep up with, to what extent do you think we should be focusing on simplifying and directing attention to a few clear a great measures that can then become kind of barometers for the system behind them, back to dr. disch this point, fundamentally the problem that is a system from actual not solve with this went on doctors for mistakes. you will solve it by recalibrate the culture and the system that supports these decisions? >> can i comment i think that's an excellent point to start with? because i can indicate there is one institution to which i said on the quality committee and they tracked 1800 indicators. now, there is no -- the staff gets cynical because they say flavor of the month. scud missile is coming over the

transom to the words the staff used to getting alignment and order would be immensely helpful. reconciliation. >> i think the focus is the on outcome measure to which he talks with the 1800 measure, love is a process measures like checklist. thinks we need to do. hospitals to have to track that but for public reporting we need outcome measures. most of the reporting we have now are process measures that don't really tells whether or not a patient after got an infection or was harmed. >> dr. pronovost? >> i think you're spot on. we report at johns hopkins will over 300 measures, and most of the outcomes are measured using billing data and there truly near worthless. we spent a ton of money. we spend money improving coding, not improving care. we know the top five causes of preventable death. as she named some of them we should likely to for infections develop measures for this and

focus on those prioritizing where people are dying. outside of health care inquired infection i did not liquidity system for ballot measures of any other harm. >> i'll change the top of a little further up the gun get a lot of head nodding so think we agree with that so far. do you believe, that if you were to pick a couple of really poor quality measures, trying to sue some of the clutter away from them so that they became much more visible, much poker, had much more signal coming off of them, that that within affect the type of system operations and the type of culture that have been repeatedly talked about? and would tend to propagate in other areas of the institution, or do you think you have to fight it, infection by infection, issue i issued against a wall of bad incentives? >> i completely agree about the overload and they think we do need to nader. the one concerned about narrowing to four or five is in

every focus group, there's a lot of other stuff that is important that doesn't get tackled, to your point. so i think part of the core metrics biggest isn't there value in punching through to real success on those and then expanding it rather than just banging against everything and not making progress? >> true but the widow make significant progress on any of them. what i was going to say is i think it's important to think about infrastructure and foundational things that will raise all the boats basically. you will not get very far any of these issues. we have measures of that. >> go to the ford plant, the biggest ford plant that makes i think the vast majority of the trucks in michigan. any person on the line can stop the line. they are protected for doing that it is any kind of a flaw if

you are right about that. it's a very good process. >> some organizations have implemented the same strategies in health care. spent the icu in rhode island but it worked very well. >> exactly the how do we incentivize improvement? just measuring it alone isn't enough. but there these engines of infrastructure in terms of that is training. we can't have our leaders telling people just try harder next time. people have to understand safety science and safety principles and make sure everybody in the organization understands how to improve things. things are happening all over the place and it has to come from the frontline to fix all of the things. >> dr. jha, dr. james real quick. >> the good news is what dundas. we've had noisy measurement programs and the federal government has taken a leadership role to the hospital only a lives. about a decade ago to find this stuff can identify a few key metrics, get everybody on board to start measuring and using it. i think because this is a public

health, i think the cdc is a national role to lead the. if we can identify the three to five big things and go after it, measure it and put it in and says because of all talk about culture, culture comes in leadership, leadership response to incentives. >> i'd like to ask you to think about a different dimension. we were doing this at nasa as i was leaving called 360-degree reviews. if you talk to nurses and doctors and hospitals, they know who's doing it right and performing well but they are afraid to say so. is there something wrong with her colleague or their boss. at 360-degree review works really well. is an anonymous review but you don't know who's reading you but you get the bag. for the first couple of years you get feedback on what you need to fix. icas and interesting feedback on what i needed to fix. doctors get that but after a couple of years, if a physician

is not fixing feedback is given, then administration take some kind of action. within hospitals it is done was going on. yet to find a way to pull that information up and get it available for the public. >> chairman, back to you. thanthank you very much. >> let me continue the questioning. i think ms. mcgiffert was talking, maybe it was dr. jha, about at the end of the day what we're talking about is patients. instead of going from patient on that we're going from on up and down division. in the course of this discussion, just several observations. dr. gandhi i believe mentioned that doctors prescribe medicine. that's therapy, and one out of four patients can't afford to buy the drugs. what kind of insanity is it because of the whole effort of someone diagnosing a disease, therapy and oh, too bad you

can't afford the drugs. dr. james talked about his own tragedy in his life, where after the treatment his son received, somebody knew they shouldn't go out and run, do heavy athletics but they forgot to tell in the photo is a lack of communication. i know as part of the aca hearings that we had, medicare will spend a lot of money doing surgery on an older person and within that person home, and she can we forget whether the person has enough food to eat, whether home is warm enough in the wintertime or whether have a clue about the kind of 15 different medicines they are taking to use than $50,000 on surgery but we don't spend $5 a day on a social worker to make sure those things are done. this piec be something to what a dysfunctional system in general, which is into a large degree if i may say so, profit oriented rather than patient-centered. want to comment on that part

true, not true? dr. gandhi. >> well, you know, i think it is true that we do not do enough to ensure patients are educated and partnering with us, patients understand the plan, the patient had the resources when they going to actually do what we asked them to do. the incentives have been outlined to pay for the. and so some of the changes around accountable care organizations and karen for population care as opposed to these distinct episodes, i think that will help to build that -- >> in terms of course, if we do a major surgery and it's not infrequent people end up coming back into the hospital in a week because they don't get the right food. that is not cost-effective. >> but in the current system that hospital gets paid again for that readmission so the hospital in the old system didn't necessary have the incentive to ensure that

everything went great once the patient lives. that's the bill challenge, incentives have been completely, or if you had a pharmacist in a primary care practice who is doctor-patient on taking drugs and explained things to them, it would help a ton but how do you actually pay for that person? incentives haven't been there. >> that is a series problem, is it not? >> elderly patients on multiple medications, it's not always caustic and the side effects, not understand why we need to take it. a primary care doctor in a 15 minute visit will have a really hard time spending an hour with someone to really explain -- >> and we pay for the lack of information and knowledge later on. >> exactly. >> dr. jha, let me ask you just with your experience in the va. which is a different type of system. what does it do better, what does it do worse, the same as what we're hearing today? >> the va has really took a leadership role in the late

1990s under the clinton administration when dr. kaiser, they made safety patient -- patient safety america. to put together a national patient, center for patient safety. they that i think leading work in this area in tracking down adverse events, understand what causes them. they have been phenomenal and a lot of it. my concern is that over the last few years there's been a look at less focus on patient safety in the va. there's been a distraction with a lot of other issues. the va in some ways represents some of the same problems we've heard about. hundreds and hundreds of metrics now, lots of focus on what matters to veterans and because of that i think we have not seen the kinds of gains in the va we would like to see and that we can get back again because the infrastructure and the commitment is there to making it a safe organization. >> ms. mcgiffert? >> i do think the va is a good

example, for example, a number of years ago they started screening incoming patients for mr sa, antibiotic resistance, a bug that people might carry on their skin. so they are mrsa infections have gone significantly down. the va put out a directive saying we're going to do this all over the country. in the private sector we cannot do that. we cannot, the only way to do it is through medicare. medicare is the big dog. they make things happen. and so i would say one of the most important things that can happen is medicare, keep pushing of public reporting, keep pushing on these incentive payments. and i do think there probably are ways they can standardize and coordinate them a little better. but this needs to keep going and i think you're going to hear from a lot of hospitals who say, stop this. but from the consumer perspective, we want to see accountability for these kinds

of events, and payment incentives are one way to do it. >> dr. pronovost, getting back to the issue senator warren raised, if you, you know maybe people in detroit are, some hospitals have rates of infections 10 times higher than another hospital, and they think what we've heard is you give them a warning, get your act together, what else? what is the or else? >> i think our regulators whether it's the same as our joint commission have all established policies for how to do this. they have largely implemented those on single complaint. so if you get a complaint from a patient has a complaint, they come and investigate a health organization, they review your policies. they could withhold medicare funding and for example. they have a great power of sanctions. what they haven't applied those offer rates of these infections. they will come in, you know, oftentimes for individuals, but

they haven't focused on this glaring -- >> you don't get your infection rate data you get a cut? >> correct. again, they have a policy for issuing sanctions to they haven't pulled the trigger for outcomes and i think we need to do, make sure, senator, that whawould they do it on the meass are valid, which again outside of h. h. either not many of them. all other states have reduced dramatically. the science is good but the signal is good and we need accountability. >> dr. gandhi? >> i did want to again reiterate because i've seen this happen, that, you know, so does one measure suddenly becomes the focus for an entire organization and they fix it, check, done, right? instead of, really changing the or position of what the organization is working on is so critical because that's one issue of many. so i think these incentives and a candidate is critical but when he does it at a higher level and maybe a single measure.

>> senator warren? >> thank you. i want to go back to point that dr. gandhi raised earlier, and that is that the commitment to patient safety can't stop when someone leaves the hospital or the doctor's office. many people come home with a prescription, or in some cases with several prescriptions. and a hefty mindy kim on their own, but unlike something as basic as aspirin, almost none of these prescriptions come with standardized regulated consumer friendly instructions. this is a huge hole in our patient safety system. it has real consequences. in 2010 alone the centers for disease control found that more than 15,000 people died from unintentional prescription drug overdoses. that's entirely preventable in my view, and entirely unacceptable. so dr. gandhi, let me just start with you.

can we assume that at least some of these overdoses have been caused by people who don't understand how properly to take their medications? >> i think that's a very valid assumption. >> okay, good. been let's go to the second part. and that is, would you conclude that in addition to the thousands of people who die from unintentional medical overdoses each year, there are probably many more people who are taking their medications and properly because they don't understand the instructions? >> well, there's very good day to say that patients are often not taking medications as they were originally prescribed. there can be a lot of reasons for the. one of which they might not understand, one might be it's really expensive and decide maybe if i take half a pill instead of what i will still be okay. there's lots of reasons for that but i think lack of understanding of how to take the medicine, what it's for, what the potential side effects are, all of those are significant

issues. >> does anyone else want to weigh in on this? >> consumer reports has spoken before congress recently within the last six months i think on the need to improve labeling and information to patients. it's a critical issue, and i think it's something that congress can do something about. >> drabout. >> dr. jha? >> i knew to parents will lost young adult children to overdose of medication. what happens is often these are opioids and there've -- be a very addictive. doctors to understand the power of addiction for these patients so they get a prescription or they don't do what they want they can go to another pane mail and get these. so there's kind of, the system needs to be fixed of that cannot happen so these young adults don't die. >> dr. disch? >> another good example of an issue that really does require patients and families conversations about the drugs, not just prescribing and saying is that we're going to put you on. because there may be information

that the patient or family has that this isn't a good drug or a taken it before, or there's a story where the patient was ordered to change his diuretic and to himself and come back in a couple of days if he gained more than three pounds, rate education but the patient was homeless and didn't have a scale. so the discussion about is this going to work for you, what are the goals, and personalizing something that seems a straightforward as a medication prescription really requires talking with a person and not just prescribing for. >> dr. jha? >> so, we have seen this happening i think in lots of other areas where we now have, we changed the lady -- change the way we're labeling for. you can put lots of data out there but if it's confusing it's worse than not having any data. we've seen progress. there's been a lot of very good work to start point to what is the kind of information you need to show patience to how do you

present in a way people can understand but this is not rocket science. people have done work on this and this is a place where i would think the fda, and begin beyond my area of expertise that because the regulating around us but seems to me this is something we have a clear role on to make the information much more consumer friendly so normal people can understand it. >> and dr. gandhi. >> so want to reiterate what dr. disch said. i agree a level of about solve this problem. it's a part of the problem but it's having those good conversation with patients about medications. the other piece is giving providers the tools about those good conversations. these patient friendly tools, electronic medical records for example, could really help to fight a nice challenge to patient of yours where you take and why and what they fix i think there are tools we need to give to provide to these conversations go well. >> very much appreciates the point on this. i'm going to summarize it this way by saying it's clear there

are dangers associated -- dangers associated with improper medications. it's also clear that we have consumer friendly liberals for over-the-counter drugs, tylenol, cough syrup. and that we do not yet have those on prescription drugs. so what i'm hearing the panel say, we won't solve everything by getting better labels but if we had a more consumer friendly labels on prescription drugs, this is one of those like washing hands. it is at least a low-cost, simple, direct way to make an improvement in patient safety that could save lives and certainty say people who have suffered. i just want to say on this one, the food and drug administration has been working on getting consumer friendly labels for more than 30 years, and we still don't have them. so this is an area where i think we should continue to push and continued to push the food and

drug administration. they have the authority to do this. we need to patient friendly labels on prescription drugs. thank you, mr. chairman. >> senator whitehouse. >> thank you, chairman. while senator warren is here, and senator murphy oyster also, i want to thank both of them. we are working together along with a few other senators on a piece of legislation to address the problem of hospital inquired infection. were looking at trying to improve the meaningfulness, if that's a word, of the data collection and the distribution of the dead is the transparency. we are looking at trying to reinforce that state-based hospital acquired infection reduction efforts because so much of this has come out of local initiatives. we are looking at improving antibiotic stewardship, and we're also looking at trying to improve the data across and

house. and that's the question that i want to ask all of you now. we have i think a fairly good sense of dr. pronovost pointed out, of the four or five elements that combine together to solve a lot of the hospital acquired infection problems. they fight appeal against incentives that cost the hospital often money, cost money gentlemen to the program and they lose the revenues that they actually got for trading the hospital acquired infection may cause. so it's a kind of a double hit to them. and in that environment where there is actual control, you've got a ceo of the hospital and the hospital system but even then we see these problems. so when you're dealing with a handoff for a patient who is going from a hospital setting to a nursing home, and very likely

back to the hospital and back to the nursing home more than once, should we be optimistic about our ability to tackle that problem while we are still having so much trouble with the first problem? and what kind of reporting do you think would be most helpful? asked first dr. gandhi because this is your expertise. ..

>> electronic medical records can help with this, and there's work going on there. but then there's also a really critical human component, and the term we've been using lately is warm handoff. if a patient is sick enough to go from a hospital to a rehab, they're going to another facility. often, i would say, the norm is nobody from the hospital is actually talking to someone in that receiving facility. the patient gets on a stretcher with the chart and goes off with no communication verbally. and we've seen that when you do that verbal communication, some really important information gets conveyed. so standardizing that entire process, content, timeliness and when do you need that person-to-person dialogue is really fundamental. and, you know, we're just starting on this, but i don't think we can wait to say, hospitals, fix yourselves until we worry about this because this

care just can't be put aside to a later point. >> and assuming, as you've said, that there are process measures that could be checklisted for that handoff, where do you think in the oversight universe the responsibility for overseeing that checklist should reside? is that an arc issue, is that a cdc issue a cms issue? >> so we could create measures. i'm not sure who it would be, but just as an example, i was at partners health care. we created a measure. we said these ten things need to be in a discharge summary. and, you know what? if you have nine out of ten, you get a zero. >> uh-huh. >> and we could measure it and improve it because we could measure it. so i think your point of there needs to be a measure and that could be tracked, i think medicare could certainly be part of this. we could figure out how to do it. and so i think that some body like medicare would make sense.

>> one important problem here is if you look at the high-tech act, which you know well, senator, and we are providing incentives for doctors and hospitals to put in electronic health records, and by all means, it's going pretty well. >> don't get me started on this one. i'm with you all the way. >> i know this is a topic near and dear to your heart. >> nursing homes and behavioral health providers when you did that, so you're not part of the -- >> i told you not to get started. [laughter] >> my apologies, senator, for egging him on. it is exactly the problem we're talking about, because the sickest, the most complicated, the most expensive patients leave the hospital and go to nursing homes, go to rehab facilities. those places do not have electronic health care records. we've tracked their data, and they're lagging way beyond. you can have a great electronic summary, and you have to print it out and fax it, and that is

no way to do business in 2014. >> understood. >> dr. dish? >> i think we have to do a little thinking here because it's actually seductive, we've talked about labeling, infections, happenedoffs and really do a deep dive on those, but we also have to step back and say if we are trying to change preventable deaths, maybe like the aviation industry did, we have to start thinking about things like high reliability organizations. we have people who do not tolerate deception, or they're preoccupied in a good sense with failure. we've got leaders that really are committed. i mean, it's -- we've got to do a both-and. but i worry we will focus on let's fix this problem of the moment, let's fix that problem, and the aviation industry had to really restructure how they did business. so that has to still be on our radar screen. >> thank you. dr. james. >> very quickly, and this goes

back a hitting bit. there needs -- a little bit. there needs to be a national standard that everybody dances to. right now there's a number of systems, and they don't communicate well. i'm not a doctor, obviously, but that needs to be fixed at the federal level, in my opinion. >> thank you, chairman. this is far and away the most important hearing happening today in washington, d.c. because of the importance of this issue, and your attention to it and this incredible panel you brought together has really been terrific. >> well, thank you, senator whitehouse. and let me, i want to concur with senator whitehouse just said. we don't know the exact number, but we are talking probably about hundreds of thousands of people a year dying from preventable problems in hospitals, and god knows how many outside of hospitals. what we do know is that this issue has not gotten the attention that it deserves, and i hope that today is the beginning of an effort to focus more light on it.

you guys -- i want to thank all of you and echo, again, what senator whitehouse said. this has been a terrific hearing. i have learned a lot. i hope people who viewed it on c-span have learned a lot. you've given us ideas not only in terms of what the problems are, but where we have to go. the role the federal government has to play in terms of the cdc, the fda, medicare, medicaid. so we have a lot to work with. and i just, again, want to thank you for all the work that you have done and for your powerful presentations today. thank you very much, and this hearing is adjourned. oh, i did want to add senator boxer wanted to put in some work on patient safety issues into the record, and with unanimous consent, we'll do that. thank you all very much. [inaudible conversations]

[inaudible conversations] >> so that wraps up this congressional hearing looking into medical mistakes and

patient safety. by the way, if you missed any of it, you can see it in its entirety online at c-span.org. we'll also bro cadst again -- broadcast it again later today at 5:35 eastern here on c-span2. here's a look at what's ahead. coming up next, a hearing on the difficulties visual hi-impaired veterans faced. and then today's edition of "washington journal" in its entirety. after that, a congressional hearing, this one on veterans' mental health. here's a look at some of our prime time programming tonight across the c-span networks. here on c-span2 at eight, it's more booktv. the focus will be on a recent "in depth" program we did with ron paul. over on c-span3, american history tv will feature our real america series. tonight we'll have films on apollo 1 is, the hover dam and a conversation with president

herbert hoover, and that starts at eight. on c-span, a look at native americans including a look at the battle of little bighorn. here's a quick preview. >> when euro-americans come out west, they want to turn the sioux and the cheyenne and the blackfoot and the crow, they want to turn them into christian farmers. well, sitting bull's not about to bend over and scratch and claw at the ground with a hoe to try to make a living. and crazy horse is not going to surrender his pony and hook it up to a plow. they're hunters and they're warriors. and that's their vision. folks, in the mid 1870s, 1873 there's an economic crisis. the stock market crashes, the banking system rolls over, the panic of 1873. people are losing their jobs, their life savings. there's 20% unemployment.

does any of that ring a bell? [laughter] it's tough times in america. ulysses s. grant is the president of the united states. he's going to have to ref up the -- rev up the economy, or he's not going to get reelected. he needs an economic stimulus package, and george custer's going to provide it. gold in the black hills. summer of '74, custer leads an expedition into the western black hills in south dakota. rumors of gold had persisted for years, but now it is a reality. there's gold in the black hills. newspaper reports say all you've got to do is walk through the grass and pick up nuggets off the tops of your shoes. [laughter] miners, prospectors, entrepreneurs pour into the hills overnight, deadwood. 3-4,000 people real quick. every one of them is an illegal alien because the black hills belong to the sioux, guaranteed by the treaty of 1868, a white man's promise.

no white people allowed in the black hills. wild bill hickok, shot in the back of the head playing cards in number 10 saloon in deadwood, he's an illegal alien. so is his friend, calamity jane. because the sioux called the hills sacred ground. well, president grant sees an opportunity there. he wants to get at that gold, rev up the economy, create jobs, put money in the treasury, so he's going to try to buy the black hills. $7 million. that's a lot of money. but sitting bull, crazy horse, ice, lame white man, others, no, not for sale. you don't sell the ground that your ancestors walked on and now their bones lie beneath. not for sale. >> and that was just a short portion of tonight's american history tour of native american sites. yo